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LG503 <br />(R«. ioanot <br />to Lawful Gambling <br />Request by a Go jf J s .. ent to Spend Gambling Funds <br />Goverrart ent In f orniatian <br />Name of Government Requesting Pumas <br />CITY OF LINO LAKES <br />Phone Numoer <br />( 612) 464-5562 <br />Address <br />1189 MAIN STREET <br />City <br />LINO LAKES <br />State <br />MN <br />Zip Code <br />55014 <br />Check type of government making request: <br />City <br />County 1 Township 1 1 School District No. of <br />, Division of <br />, Division of <br />State of Minnesota, Department of <br />United States, Department of <br />J Other Govemmental Entity - specify <br />aruzation Information . <br />Organization <br />Phone Number <br />f ) <br />License Numoer <br />Address <br />City <br />State <br />Zp code <br />Lazvfitl:Purpose-Request <br />The above-named government requests laf gambling pro <br />(explain expenditure - attach additional sheets if necessary. <br />s for <br />e fa <br />wing purpose: <br />SCHOOL SAFETY PATROL SUPPLIES SEE ATTACHED SHEET <br />Amount requested <br />$ 1,056.74 <br />ROLLERSKATING APPRECIATION DAY FOR VOLUNTEER SCHOOL SAFETY PATROL SEE ATTACHED <br />SHEET <br />• By completing and signing this form, the govemmenrs agent confirms that the requested funds will be spent for a lawful <br />purpose. This request expires one year from the date below and may be renewed at the request of the local governing body. <br />Use of Form: j <br />1. If an organization wishes to contribute gambling funds to a governing body, the governing body must complete this form. <br />2. Aooroval of the Gambling control board Is not reaulred, <br />3. The form should be kept on file by the licensed organization. <br />4. <br />•11- / <br />0 <br />0 <br />1 :• u <br />;.••g <br />0 <br />1. 1• n 1. 1 1 z <br />