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C04G 5 0 3 � <br />(Pev. V 1 /'90) <br />V0% <br />sicequest Ver a Government to, Spent. Gambliffiff Flund,r� <br />Y 4;7 <br />-1 4 it <br />Name of Government Phone Number <br />Address city Ulate Zip GW'e <br />Check type of government making requ�est <br />City County Township School District No., of <br />W� State of Minnesiota, Department oil , Division of <br />0 <br />United States, Department ent of Division, of <br />In on R <br />Organization Phi6ne-flumber License Aumber <br />Address, City State Zip code <br />The above-namied government requests lawful gambiling pirofilts flor (explain expend�itu�re- attach additional sheet it necesary <br />Amount requested <br />$ <br />Check one: <br />E] initfilLting, performling or fostering worthy pubilic wlorks: <br />EI Orecting or maintaining public structures: <br />lessiening the governmientlis burdens: <br />voluntarily supporting, augmenting, or supplementing services that the government would usually perform: <br />Print name <br />(I-so of Foirm.- M <br />*if an organization wishes to iexpeind gambling fu�n�ds on behalf of a govern"Ing bodylli Ihe governing body must complete this <br />I <br />mirm. AoDpok-���e Gainbilia Covtrol Board' Is not reTWred. <br />