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Minnesota Lawful Gambling <br /> LG555 - Government Approval or Acknowledgment For Use of <br /> Gambling Funds (previously LG503 and LG265) (10/01) <br /> • Organization Information (please print) ` <br /> Q#VRCN <br /> Organization Name K� t= 1If/ES CJ �.f 1 y o2fif,�0�X License Number _ 4 3 i6Y6 <br /> (t:�o (iJ ffw <br /> Address 4,eL.cJ if iCCS M,cJ SS t l2 <br /> Expenditure Description (attach additional sheets if necessary) <br /> 1. Amount of proposed lawful purpose expenditure $ =9 � _ <br /> 2. Check the appropriate expenditure category: <br /> Contribution to a unit of govemment -United States,state of Minnesota,or any of its subdivisions, <br /> age^ i1 ev-inctnlmPstalities. NOTE: A contribution may not be made directly to a law enforcement or <br /> pro <br /> _ Awl SAINT KATHERINE UKRAINIAN ORTHODOX CHURCH 75-562/960 1267 <br /> autt POT O' GOLD GAMBLING ACCOUNT 2011187 <br /> 1600 HVVY. 96 DATE <br /> DE w AROEN HILLS, MN- 55112 <br /> PAY TO THE 49 <br /> ORDER O 11 <br /> _Gro, <br /> oPi <br /> D LARS L+l <br /> Di ie�Nationat Bank <br /> �651)631-I090 <br /> I501"t9 Cowry Read C,Roeevl9e.M1R.155113 <br /> MEMO <br /> `1:09600 5G 241: 20 1 L L8 ?its - <br /> Oath 0 L 2 G 7 <br /> • I affirm t <br /> result in any net monetary gain or other pecuniary benefit to our organlzaclon. <br /> • I affirm that when lawful gambling funds are used for grooming and maintaining snowmobile or all-terrain vehicle trails <br /> or for/any wildlife management project for which reimbursement is received from a unit of government,the reimburse- <br /> m� nds u� rA deP4s�ed In our lawful gambling account and recorded on the LG1010-Schedule C/D report. <br /> Chief executive officer's signs r Phone number Date - - <br /> Government Approval/Acknowledgment <br /> By signature below, the representative of the unit of government <br /> • approves the project as described-above, and/or <br /> • acknowledges the <br /> contribution,which <br /> )willnoot be used for a pension or retirement fund. / [ <br /> Unit of 'Government Cr r / 10A " r,l`ILL Phone number 60 <br /> J`� <br /> 2�5 ,�� b y Cit 4JZOLzJ <br /> Address /y�LLS State +•W Zip `01 Z <br /> Print Name L— Title U f / f `��1�'4•"L- <br /> Signature >� Date 07 l Q-Z 1 2� <br /> Keep weepy e*this completed form attached to the LG1010-Schedule C/D in your organization's records. <br /> This form will be made available in attemative format(i.e. The information requested on this form will become public <br /> large print, Braille)upon request. If you use a TfY,you can information when received by the Board, and will be used to <br /> call us by using the Minnesota Relay Service at 1-800 62T- determine your compliance with Minnesota statutes and rules <br /> 3529 and ask to place a call to 651-639-1000. governing lawful gambling activities. For additional <br /> information,check our web site at ww.gcb.state.mn.us <br />