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Minnesota Lawful Gambling
<br />Government Acknowledgment Form - LG503
<br />Use of This Form
<br />1. If an organization wishes to contribute gambling funds to a
<br />unit of government, the organization and unit of govern-
<br />ment must complete this form.
<br />2. Approval of the Gambling Control Board is not required.
<br />3. The form must be kept on file by the licensed organization.
<br />4. Attach a copy of this form to your Schedule C report for
<br />the month in which the funds are spent.
<br />Lion
<br />Certain Contributions Prohibited
<br />Minnesota Statutes, section 349.12, subdivision 25(b)(6), pro-
<br />hibits "a contribution to a statutory or home rule or charter
<br />city, county, or town by a licensed organization with the
<br />knowledge that the governmental unit intends to use the
<br />contribution for a pension or retirement fund."
<br />Minnesota Rules, part 7861:0120, subpart 5D(10), prohibits
<br />"any contribution or expenditure to the extent that it
<br />results in any net monetary gain or other pecuniary benefit
<br />to the organization making the contribution or expenditure."
<br />- -a- --
<br />Orr%fganiiation (� /� J
<br />Ate" ,AI Lie Relet ffssac:.
<br />Phone Number
<br />(6.5-7 ) 7e/— 7y 7P
<br />License Number
<br />j_,,D30j 7
<br />Address
<br />779; La-k.,. .Ir,, e,
<br />City
<br />2,'..., ,... ,Za- k cs
<br />State
<br />_ /l• /t/
<br />Zip
<br />SSo / y
<br />gCity
<br />❑ State of Minnesota, Department of , Division of
<br />Amount of lawful purpose contribution to the unit of government:
<br />$ /9 x1.2
<br />Amount of lawful purpose contribution rtceived:
<br />We are aware of the restrictions contained in Minnesota Statutes, section 349.12, subdivision 25(b)(6); and
<br />Minnesota Rules, part 7861.0120, subpart 1 `.
<br />‹.._. " j q Signature of Chief Executive Officer (CEO) A J t
<br />Print Name 1`�\\ ///�
<br />�I.J C'S 1,,„,,,,,,e �NL� IUn oC
<br />Date ZU — C)-C1
<br />/
<br />Name of Government
<br />City of 1-1r,0 bet kes
<br />Phone Number
<br />(Lb )) 9S'. -I- yea
<br />Address / Dp
<br />4030 /e;w h CH4 I � f ' w y
<br />City
<br />4/1;‘, / 4/t ei
<br />State
<br />A14
<br />Zip
<br />5.5.
<br />_
<br />Check type of government:
<br />❑ County ❑ Township ❑ School District No. of
<br />gCity
<br />❑ State of Minnesota, Department of , Division of
<br />nUnited States, Department of , Division of
<br />•
<br />nOther Government Entity - specify:
<br />Amount of lawful purpose contribution rtceived:
<br />$ /C}) %a3
<br />/
<br />% 0,04111-"""76-
<br />We are aware of the restrictions contained in Minnesota Statutes, section 349.12, subdivision 25(b)(6); and
<br />Minnesota Rules, part 7861.0120, subpart 5D(10).
<br />Signature of Government Agent
<br />Print Name (, 0.1.,.
<br />Title At, f.l ,101_ et.}l, A40444, gi-ru .4-�
<br />22tory 2
<br />Date
<br />The information requested on this form will be used by the Gambling
<br />Control Board to determine compliance with Minnesota statutes and rules
<br />governing lawful gambling activities. All of the information supplied on
<br />this form will become public information when received by the Gambling
<br />Control Board. This form will be made available in altemative format
<br />(i.e. large print, Braille) upon request. If you use a TTY, you can call us
<br />by using the Minnesota Relay Service at 1- 800 - 627 -3529 and ask to place
<br />a call to (612) 639 -4000.
<br />(Rev. 1018/96)
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