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Minnesota Lawful Gambling <br />Request by a Government to Spend Gambling Funds <br />Goverriirient Information. <br />Name of Government Requesting Funds <br />Lino Lakes Police Department <br />Phone Numoer <br />( 612) 780-0605 <br />Adoress <br />7731 Lake Drive <br />City <br />Lino Lakes <br />State <br />MN. <br />Zp Code <br />55014 <br />Check type of government making request: <br />X <br />City <br />I 1 <br />County f 1 Township 1 School District No. of <br />l 1 State of Minnesota, Department of , Division of <br />1 1 <br />United States, Department of <br />, Division of <br />Other Governmental Entity - specify <br />Organization In forrnatiart <br />Organization <br />Ac•D/gS !u.r// A.4 <br />frz/ 6-4-Y3 <br />Phone Number <br />(67" ) . r- / <br />Aaadre/ss. City State <br />7 <br />�G`,tAx-G De J f nJ6 , \M h S fG L <br />License Numbef <br />0G/i-c0/ <br />Zp coca <br />Lawful Purpose Request <br />The above-named government requests lawful g—amobng profits for the following purpose: <br />(explain expenditure - anach additional sheets if necessary. <br />Support of the D.A.R.E. Program within Lino Lakes and Rice Lake <br />Elementary Schools. <br />Amount requested <br />$ /I c•07) <br />Educational Materials used during the 17 week program. $4,300.00 <br />Wages for D.A.R.E. Instructor. <br />$8,000.00 <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 />S.gnaau• pov.mm.i agent <br />Pnnt nam. <br />I Tit7. <br />Chief of Police <br />0at. <br />01-19-95 <br />Use of Form: <br />1. If an organization wishes to cJnnnbute gambling funds to a governing body, the governing body must complete this form. <br />2. Aporovaf of the gambflno Control @card la not rsoulred _ <br />3. The form should be kept on file by the licensed organization. <br />4. o• o lou . .0 •••ul: ;••.g o .n 1 whl tuna •r• seen <br />