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Minnesota Lawful Gambling Schedute C/D - LG1010 General Information Organization name , . ' u . • - - u x a .. - license number A -00562 Month/year reported: 0 3 i Ci Page 2. of 3 pages Is this an amended Schedule C/D? Y N iedule C: Lawful Purpose Expenditures Check here if no Schedule C expenditures for this month: ❑ Current Monthly For Code Membership Date of Check TRCS A A -7 Only Approval Date Check Number Check Made Out To: '1 Code Maw Female Amount a,- 3-99 3129 '113$2 tiT' D F COTTrr(,E 612OV!✓ A - 155.63 _ A43 -99 Sin ill ti35 MP4.5 FINI NCE DEPkg-TM.ENT Azg 4n.al a -a3 3(231 4139'} CA 71 b F Cu u.cT -1 A 6 1. 61 ? - a3 - Q9 31)4 41317 G(Tki OF oP65F-1- A -08 ( 0 3 .99 a -a-gq 3122191 4 (.►'TM Dc A Ft N 6Ate a -fir 3219 7 243 -G9 3laa199 41 cum o6 I N hG PEMpCNC' A - ' c 1010•103 a - 23 - 99 3 I iqy L P L IOI C-111 OF FQEEBbR.N A-OS 9 -off a- 2 3122 -1q9 4i'104- ccvkl DE CIOQu ET A -O$ 1 a a3 X19 .31aalea 4 4 C L o NkMPLEVt EW A_oS' I I 4elscAe a -a3 - 99 31,9,21 41414 Cl Ty OF ia-cK SON A -ov ao.90 i f Oniv Total of all Schedule C Lawful Purpose Expenditures Enter the amount from line 14 of the Tax Savings Worksheet in the {or this month $ ° ahedule C/D Instruction Booklet $ Enter on line 41 of Monthly Summary &Tax Return G-1. _ hedule D: Board Approved Expenditures Check here if no Schedule D expenditures for this month: 0 Board Current Monthly Date 1RCS 6 ABoarda Membership of Check J Code Amount Date Approval Date Check Number Check Made OutTo: B- 11:— B- 63-A7 Board - Approved Expenditures for Recreational, Community, & Code Athletic Facilities Intended Primarily for Persons Under Age 21: Imo 1 Male I F.maw Total Schedule D Board- Approved Expenditures $ Signatures Enter on fine 42 of Monthly Summary &Tax Return G-1. I declare that this Schedule CID is correct and complete to the best of my knowledge and belief. / Chief Executive Officer. Date: Date: f— Gambling Manager. Mail to: If you use a TTY, you can call the Board by using the Minnesota Relay Service at 1-800-62735 nn B k iiiio Gambling Control Board place a call to (612) 639 -4000. This form will be made available in alternative format (i.e. large p t, Suite 300 South upon request 1711 West County Road B The information requested on this form will become public information when received by the Board, and will t Roseville, MN 55113 used to determine your compliance with Minnesota statutes and rules governing lawful gambling activities.