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<br />, <br /> <br />Minnesota Lawful Gambling <br />LG555 Government A~proval or Acknowledgment <br />For Use of Gambling Funds (p",vlouslyLG503andLG265) <br /> <br />(06/03) <br /> <br />Organization Infonnation (plasse print) . <br />OrganizatlooNama Pe<<oe 0,...,1.., .1;..././1""" cL-~ LlcansaNumbar 13-038t20 <br /> <br />AddIllSS /-0. /$<91C 'l'f// //.-->0 ~-t/ ~3B <br /> <br />Expenditure Description (attach additional sheets if necessary) <br /> <br />1. Amount of proposed lawful purpose expenditure I $ .3, C z. '/. &lo I <br /> <br />2. Check the appropriate expenditure category: <br /> <br />X A. Contribution to a ;nlt of government - United States, state of Minnesota, or any of its subdivisions, <br />agencies, or instrumentalities. NOTE: A contribution may not be made directiy to a law enforcement Or <br />prosecutoriaJ agency, such as a police department, county sheriff, or county attorney. <br /> <br />_ B. A wildlife management project that benefits the public at large with approval of the state agency that <br />has authority over the project. <br /> <br />Describe the proposed expendnure, including vendolS. <br /> <br />_ C. Grooming and maintaining snowmobile or all-terrain vehicle trails with appmval by DNR. <br />Ail trails must be opan to public use. <br /> <br />Describe the proposed expendilure, Including vendors. <br /> <br />Oath <br /> <br />. I affinn that the contribution or expenditure, in accordance with Minnesota Rules 7861.0120, Subpart 5D(10), does not <br />result in any net monetary galn or other pacuniary benlllit to our organization. <br />. I affirm that when lawM gambling funds are used forgrooming and mainlainingsnowmobile or alHerrain vehicle trails <br />or for any wildlife management project for which reimbursement is received from a unit of govemment,the reimburse- <br />mant funds must be deposited in our lawful gambling account and recorded on the LGl 010 - Schedule C/D report <br /> <br />Chief executive oflIcer's signature <br /> <br />, <br />Phone number <br /> <br />----1----1_ <br />Date <br /> <br />Government Approval/Acknowledgment <br />(Check one) By signature below, the representative of the unit of government <br />~ acknowledges Ihe contribution in 2A above, which will not be used for a pension or retirement fund. <br />_ approves the wildlife management project as described in 28 above (state agency only). <br />_ approves the expenditure forgll>Oming and maintaining snowmobile andJor ail-terrain v&hide trails described <br />In 2C above (DNR only), <br />UnitofGovemment Phonenumber <br /> <br />Add..... <br /> <br />4 <br /> <br />City <br /> <br />~-~ <br /> <br />PrintName <br /> <br />~', . <br /> <br />Tille <br /> <br />SiJnalulll <br /> <br />Data <br /> <br />I <br /> <br />/ <br /> <br />Keep this completed form attached to the LG10l0 - Schedule C/O in your organization's records. <br />You do not need to submitlhis form to Ihe GanIi>ling Conlrol Board. <br />This foon will be made available In a1tematlvefonnal Q.e. will become publlclnfonnallon, when ""luested by the Board, <br />large prin~ Braille) upon requesL Wyou use 8 TTY, call us and will be usad to determine youroompllanoa with <br />by using the Mlnnesola Relay SeMce end ask to place a call Minnesofa statutes and ndasgovemlnglawful gambling <br />to 651-639-4000. The Informalion requested on this form aclMlles. Foraddlllcnallnfonnation, chack ourweb site at <br />www.gcb.s13te.mn.us <br />