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MINNESOTA JOINT UNDERWRITING ASSOCIATION <br />PIONEER P.O. 30X 1760 <br />ST. PAUL, MN 55101 <br />1- 800 - 552 -0013 OR (612) 222 -0484 <br />Insured and Address: <br />LITTLE CANADA RECREATION ASSOCIATION INC <br />DBA: RICHARD EDWARD BOSS IV. <br />72 E. BRYAN ST. <br />LITTLE CANADA MN 55117 <br />Policy Number: LL00 -8196 <br />TO WHOM IT MAY CONCERN: <br />Please respond to the following questions with respect to coverage provided by <br />the Minnesota Liquor Liability Assigned Risk Plan under the above - named <br />policy. <br />Date of Sales Gross Liquor Sales by Day <br />08/04/00 <br />08/07/00 <br />to <br />S <br />Copies of deposit tickets and/or a summary Income) statement verifying :he <br />sales figures above are recuire_^. Copies of ocher accounting ^ - -e2 <br />may be helpful to complete _his audit should be sent. If aft__ reviet/ _4 -.e <br />information you submit/it is determined that additional records are <br />you will be contacted to set up an audit appointment. <br />This form is to be filled out and signed only by a Representative of the <br />Insured and returned to us within 15 days. <br />Person Completing Form (PRINT) <br />Title i€)9' St:'g ?hone No. <br />/.uz, rr /lrt <br />PAGE 24 <br />.%/ <br />