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PI <br />LG503 <br />mecimeol <br />• <br />Minnesota Lawful Gambling <br />Request by a Government to Spend Gambling Funds <br />• `lime t b.tritatto. <br />Name of Government Requesting Funds <br />City of Lino Lakes <br />Phone Number <br />(651) 982 -2400 <br />Address <br />600 Town Center Parkway <br />City State <br />Lino Lakes MN <br />Zip Code <br />55014 <br />Check type of government making request: <br />1 1 <br />1 1 <br />City ( County <br />Township <br />State of Minnesota, Department of <br />United States, Department of <br />Other Governmental Entity - specify <br />School District No. of <br />, Division of <br />Division of <br />.. <. .v<!• <t: ^••..: Vi:!!;:<..: i!!! <:;!!p!..:i:....:>!i.'!:.:. /,.- ::{4 ?v;<SYY.:: iii!!V ••: <br />% :x< <br />4:. <br />a <br />CtTti.2 TL. 11.. <br />rmaz� �r <br />License Number <br />e,e;c' -Oe)1 <br />Zip code <br />Sro1 <br />Organization Phone Number <br />Cu:1CLE- -1-Ex jif tJ 6553 (60 ) 75 r3t3 <br />Address City State <br />'7 ` Lir /(f 17 r VE 1-iNo /-- I MS <br />ues <br />e a••ve -named government requests la u gam • ing pro its or t e o lowing purpose: <br />(explain expenditure - attach additional sheets if necessary. <br />Amount regt,ested <br />By completing and-signing this form, the government's 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 />g re of government agent <br />Print <br />3-e,ck_ lei IA <br />Date <br />- `9, <br />Use of Form: <br />1. If an organization wishes to contribute gambling funds to a goveming body, the governing body must complete this form. <br />41K. Approval of the Gambtlna Control Board Is not reaulred, <br />. The form should be kept on file by the licensed organization. <br />4. Attach a copy of this 10r <br />11 • • <br />• 1;a• <br />;•••ig • <br />1; 11 • I 1 1 • 1 1 1: L 1•• • -•; 1 <br />