Fireworks Certificate Transfer of Ownership Affidavit from Original Owner

Department of Licensing & Regulatory Affairs Bureau of Fire Services, PO BOX 30700, Lansing, MI 48909

Phone: (517) 241-8847 - Fax: (517) 332-1427 - Email: Fireworks@michigan.gov

NOTARY PUBLIC Subscribed and sworn to before me, A Notary Public, on

Date Form Received:

BFS - 401 (Rev 9/16)

I, agree to transfer ownership of

(print or type full name of original certificate holder) consumer fireworks certificate number (print or type full certificate number)

to (print or type full name of new certificate holder)

Fireworks Safety General Rules: R 29.2906 Transfer of certificate. Rule 6. (1) A consumer fireworks certificate is transferrable in accordance with section 4(6) of the act, MCL 28.454(6). (a) A new applicant shall submit an application and other required information, other than plans, with a $25 transfer fee. (b) The consumer fireworks certificate may be transferred to a new entity that is in the same physical location and that has had no modification made to the facility since the last required inspection. (c) The consumer fireworks certificate for a temporary facility may be transferred to a new location upon the submission to the bureau of an application for location transfer that meets all of the following: (i) The bureau received the application not later than June 1 of the certificate year. (ii) No changes were made to the submitted plans other than site location. (iii) No previous inspection was conducted. (2) Not more than 1 entity or location transfer is permitted per certificate per year.

, 2015

, Notary Public

County, Michigan.

Date of signature:

FOR BUREAU USE ONLY

effective on

Commission expires:

Signature of original certificate holder:

Payment of this certificate is to be settled between the original and new owners. The State of

Michigan is not responsible for the payment process in an Ownership Transfer. If the original

owner paid for the Certificate fee the system will recognize that payment. The State of Michigan

will NOT act as a third party for the transfer of funds between the two parties.