2012-03-07 Set Agenda w/Handouts

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Minnesota Lawful Gambling - 6110 LG555 GovernmentApproval orAcknowledgment For Use of Gambling Funds Keep this completed form attached to the LG 1010 Schedule C in yourorganization's records. You do not need to submit this form to the Gambling Control Board. Organization and . Information (attach add ts necessary) • Organ¢ation name D aa (,4..e-ke._ s [ C/l number Address Y- _o-s .e 1 —_ 7 7 / . // ' `^. 1 o t V N» J .c ll _— - – -•- 1. $ S � Do0.. n 0 Amount of proposed lawful purpose expenditure • 2. Check one expenditure category. A. Contribution to a unit of govemment - United States, state of Minnesota, or any of its subdivisions, X A agencies, or instrumentalities. NOTE: A contribution may not be made directly to a law enforcement or prosecutorial agency, such as a police department, county shelf, or county attomey. B. Wildlife management project or activity that benefits the public at large, with approval by the DNR — C. Grooming and maintaining snowmobile or all- terrain vehicle trails established under Minnesota Statute 84.83 and 84.927, including purchase or lease of equipment, with approval by DNR, All trails must be open to public use. — D. Supplies and materials for safety training and educational programs coordinated by the DNR, including the Enforcement Division. E. Citizen monitoring of surface water quality testing for public waters by individuals or nongovernmental organizations, with Minnesota Pollution Control Agency (MPCA) guidance on monitoring procedures, quality assurance protocols, and data management, providing that data is submitted to the PCA. 3. D9ibe t e propo •• ex• - nditure, including vendors. , Ii... .. r . i /� • 1 • NO FINANCIAL OROTHER BENEFIT: I affirm thatthe contribution orexpenditure does not result in any monetary, economic, financial, or material benefit to our organization, in compliance with Minnesota Rules 7861.0320, Subpart 17C. • FOR DNR-RELATED PROJECTS: I affirm that when lawful gambling funds are used for grooming and maintaining snowmobile or all- terrain vehicle trails or for any wildlife management project for which reimbursement is received from a unit of govemment, the reimbursementfunds must be deposited in our lawful gambling account and recorded on the LG1010 Schedule C report. • FOR SURFACE WATER QUALITY TESTING: I affirm that MPCAguidance has been consulted in developing the monitoring plan and that the data collected will be submitted to the MPCA. Send form forsignatu re to: Manager, Water Monitoring Section, Minnesota Pollution Control Agency, 520 Lafayette Road North, St. Paul, MN 55155. Website iswww.pca.state.mn.us. 1 / Chief executive officer's signature Daytime phone number Date Print name Gove AppravaIIAcknowledgm0 'k Check one By signature below, the representative of the unit of government. ✓ Government • acknowledges the contribution which will not be used for a pension or retirement fund. _ Wildlife DNR - approves the wildlife management project or activity. Trails DNR - approves the grooming /maintaining of snowmobile and /or all - terrain vehicle trails. Safety training DNR - approves the supplies/materials for DNR safety training and educational programs. Water quality testing - MPCA approves the surface water quality testing project. Unit of Govemment L 0 (e,r,ktr -J % -- . (� p Phone number 651 M-1 5 Address \ ti i b c t*c . S V - City `t-, fir` ,, State rke Zip CiV 3 fa Print Name M, � , tai 4 t S U ' Title t..f orrk i- 0w,t J - "--- Signature - 1/^ I , Date 3 I Z 1 I L Questions? Contact the Gambling Control Board at 651-639-4000. This form will be made available in altemative format (i.e. large print, Braille) upon request. The information requested on this form will become public information, when requested by the Board, and will be used to determine your compliance with Minnesota statutes and rules goveming lawful gambling activities.