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• <br /> Minnesota Lawful Gambling <br /> LG555 Government Approval or Acknowledgment <br /> For Use of Gambling Funds (pfevou&yLGS03and LG265) (01133) <br /> Organization information )/ � ) �f 02-,0-1- <br /> organ adon <br /> Name ! ttlx(C/4 6 / i ejo?f. ?Uanw Numbr o Address Po - Bax e P . (O d N s‘ w <br /> Expenditure Description (attach addltlonalaheetilfneoeasary) <br /> 1. Amount of proposed lawful purpose expenditure I $ S 00 iris <br /> 2. Check the appropriate expenditure category: <br /> V A. Contribution to a unit of government-United States,state of Minnesota,or any of Its subdivision, <br /> agencies,or Instrumentalities. NOTE: A contribution may not be made directly to a law enforcement or <br /> prosecutorial agency,such u a police department,county sheriff,or county attorney. <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 /> Describe the proposed expenditure,Including vendors. • <br /> • <br /> _C. Grooming and maintaining snowmobile or alt-terrain vehicle trails with approval by DNR <br /> All trails must be open to public use. <br /> ft <br /> Describe the proposed expenditure,Including vendors. <br /> Oath <br /> • I affirm that the contribution or expenditure,In accordance with Minnesota Rules 7681.0120,Subpart 50(10),does not <br /> result In any net monetary gain or other pecuniary benefit to our organization. <br /> • I affirm that when lawful gambling funds are used for grooming and maintaining snowmobile or all-terrain vehicle trails <br /> or for any wildlife management project for which reimbursement Is received from a unit of government,the reimburse- <br /> ment funds must be deposited In our lawful gambling account and recorded on the LG1010-Schedule CM report. <br /> Chief executive officers signature Phone number Date <br /> Government Deis <br /> Government Approval/Acknowledgment <br /> (Check one) By signature below, the representative of the unit of government <br /> — acknowledges the contribution in 2A above,which will not be used bra pension or retirement fund. <br /> _ approves the wildlife management project as described In 28 above(state agency only). <br /> approves the expenditure for grooming and maintaining snowmobile and/or all-terrain vehicle trails described <br /> In 2C above(DNR only). <br /> UnitorGover v C l i}l d r &0‘)(4611`k.. Pan/< D2FJT •phone number <br /> Address <br /> State Zip <br /> 7 <br /> Print Name 4' i"� ��i h-L The f�r !�/ C �[`' <br /> Signature { � / <br /> Dec. /Lh / / 7l 0 <br /> Keep this completed form attached to the LG1010-Schedule C/D In your organization's records. <br /> You do not need to submit form to the Gambling Control Board. <br /> This form will be made available In altamative format(Le. will become public Information,when <br /> large print.Braille)upon request if you use a TTY,call us and wt1 be used to detamtlne � �by ' <br /> by using the Minnesota Relay Service and ask to place a cap Minnesota statutes and rules 0:Neming lawful gambling <br /> to 651-639-4000. The Information requested on this form activities. For additional intimation,c our web ske at <br /> w-0cbstaba.mn.us <br />