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<br />Minnesota Lawful Gambling fEB 0 1 :2'U02 <br /> <br />I. LG555 - Gover!1ment Approval or Acknowledgment For Use of <br />Gambling Funds (previouslylG503andlG265) (10/01) <br /> <br />, Organization Information (please print) . <br /> <br />Organization Name go....\~ L<l..1C.P f.,R~ Lit!JAf~ LicenseNumber It-t:JCJ5"Jl([ <br /> <br />Address X'1./'$.7. ~.........;,-~\"d"j"" r.pV'""jLH~_ ~,.c. Jfttu bJ:C{}'2. <br /> <br />Expenditure Description (attach additional ineats ifnecessary) <br /> <br />1. Amount of proposed lawful purpose expenditure I $ {q /-?. .~ I <br /> <br />2. Check the appropriate expenditure category: <br /> <br />-it.. Contribution to a unit of government - United States, state of Minnesota, or any of its subdivisions, <br />agencies, or instrumentaiities. NOTE: A contribution may not be made directiy to a law enforcement or . <br />prosecutorial agency, such as a police department, county sheriff, or county attomey. <br /> <br />I that beneflts the public at large with approval of the state agency that has <br /> <br />I(~- <br />Loo <br />f~ <br />-fL <br /> <br />1/ 3cJ / If ';;.... <br /> <br />t!lre,' including'vendors. <br />.. . . <br /> <br />. <br /> <br />.(7. zL 4 <br />U1~~ <br />"~~-4~. <br />iJ~. <br /> <br />. <br /> <br />)wmobile or ail-terrain vehicle trails with approval by DNR. All trails must be <br /> <br />Jre, including vendors. <br /> <br />Chief executive officer's 'signature <br /> <br />ure, in accordance with Minnesota Rule 7861.0120, subpart 5D(10), does not <br />pecuniary benefit to our organization. <br />are used for grooming and maintaining snowmobiie or all-terrain vehicle traiis <br />Jr which reimbursement is received from a unit of government, the reimburse- <br />. O' ..Ntul gambling account and recordad on the LG1010 - Scheduie CID raport. <br /> <br />.1 I <br /> <br />Phone number. <br /> <br />Date <br /> <br />I <br /> <br />Date <br /> <br />;?I? <br /> <br />I ttJ ;< <br /> <br /> <br />Keep a copy of this compieted form attached to the LG1D10 - Schedule GID in your organization's records. <br /> <br />This form will be made available in altemative format (Le. <br />large print, Brailie) upon request. If you usa a TrY, you can <br />call us by using the Minnesota Reiay SelVice at 1-800-<;27- <br />3529 and ask to place a call to 651-639-4000. <br /> <br />The information requested on this form will become public <br />information when received by the Board, and will be used to <br />determine your compliance with Minnesota statutes and rules <br />governing lawful gambling activities. For additional <br />information, check our web site at WN.gcb.state,mn.us <br /> <br />:#=- J I "3'7 C) <br />