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LG503 <br />(Rev.10/8190) <br />Minnesota Lawful Gambling <br />Request by a Government to Spend Gambling Funds ' <br />Government 7i%#ormation <br />Name of Govemment Requesting Funds <br />CITY OF LITTLE CANADA <br />Address <br />515 EAST LITTLE CANADA ROAD <br />City <br />LITTLE CANADA MN <br />State <br />Phone Number <br />( 612 ) 484 -2177 <br />Zip Code <br />55117 <br />Check type of government making request: <br />x <br />I <br />City County Township School District No. of <br />, Division of <br />United States, Department of , Division of <br />State of Minnesota, Department of <br />Other Govemmental Entity - specify <br />Orgcdi nation 7rcfarr cafxorc ;: <br />Organization Phone Number <br />L,fr ('.a- 44472,4 e4-4/412144,1 D4VS (OA) q4 i -/, fao <br />Address City State <br />T "lC�-1-t_ -C- C- PKcvq ,57 P,a-a 14.1J <br />License Number <br />43 aq-.2f9 <br />Zip code <br />ssfr7 <br />The above -named government requests lawful gambling profits for the following purpose: <br />(explain expenditure - attach additional sheets if necessary. <br />,4RK SNg.t i E.12 4A) a-t <br />Amount requested <br />SAC, coo. 00 <br />By completing and signing this form, the government's agent confirms that the requested funds w'll be spent for a lawful <br />purpose. This request expires one ear from the date below and may be renewed at the request of the focal governing body. <br />Si of government agen <br />Tine <br />loFG 71.9./do <br />oats <br />• i i iaz /qJ <br />Use of Form: <br />1. If an organization wishes to contribute gambling funds to a governing body, the governing body must complete this form. <br />2. Approval of the Gambling Control Board Is not recurred, <br />3. The form should be kept on file by the licensed organization. <br />4. Attach a copy of this form to your Schedule C Report for the month In which the funds are spent, <br />Page 41 <br />