10.01 - Fire Relief Association Request to Increase Annual Benefit Level from $1,800 to $2,500

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rm SC-04 PEQUOT LAKES / Page 5 pis Schedule must be fully completed, certified by the relief association officers, forwarded to e i,,,iicipal clerk on or before August 1,2004 and submitted to the State Auditor's Office to eligible for state fire aid. OFFICER CERTIFICATION Ve, the officers of the Pequot Lakes Relief Association, certify that this schedule was prepared under Minn. Stat. § 69.772 and that the annual benefit level was established ccording to the average amount of available financing. Ve further certify that based on the financial requirements of the Relief Association's Special Fund for .ie 2004 calendar year, the required 2005 municipal contribution is $ 12644 . If the bylaws of the relief Association changed in 2004,we have attached a copy of the amendment or updated bylaws. A4 Ve have also enclosed a copy of the municipal ratification of this amendment if required under 5� 4inn. Stat. § 69.772, subd. 6. Ro 9131+ Signature of President Print Name Date 4 Or SAE Signature of Secretary Print Name Date Signature of Treasurer Print Name Date MUNICIPAL CLERK CERTIFICATION (For relief associations affiliated with municipal fire departments only.) am the municipal clerk of I received on ,the )mpleted Schedule from the Pequot Lakes Relief Association. I have reviewed ines 14 and 21 of the Schedule. If either Line 14 or Line 21 show a required municipal contribution, `�,Q�S certify that I will advise the governing municipal body of any required municipal contribution at its �� "SAG + -xt regularly scheduled meeting. V0 st Signature of Municipal Clerk Print Name Date Buss Telephone ease retain a copy of the Schedule for your records and submit the signed original to: State Auditor's Office,Pension Division, 5 Park Street, Suite 500,Saint Paul,MN 55103. Fax: 651-282-5298. Telephone: 651-282-6110.