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• Minnesota Lawful Gambling Government Acknowledgment Form - LG503 Use of This Form 1. If an organization wishes to contribute gambling funds to a unit of government, the organization and unit of govern- ment must complete this form. 2. Approval of the Gambling Control Board is not required. 3. The form must be kept on file by the licensed organization. 4. Attach a copy of this form to your Schedule C report for the month in which the funds are spent. ormation Certain Contributions Prohibited Minnesota Statutes, section 349.12, subdivision 25(b)(6), pro- habits "a contribution to a statutory or home rule or charter city, county, or town by a licensed organization with the knowledge that the governmental unit intends to use the contribution for a pension or retirement fund." Minnesota Rules, part 78610120, subpart 5D(10), prohibits "any contribution or expenditure to the extent that it results in any net monetary gain or other pecuniary benefit to the organization making the contribution or expenditure." Organization Re-k f ..ss e C.. Phone Number (65-)) 784,- 7.‘-/ 7.2 License Number • !_� _p3 n / 7 Address 7 % � / Lo-kt .N r, i t- City ,Zi--, v 2a-1 " State fri/t/ Zip ,-s-s -O i H State of Minnesota, Department of , Division of Amount of lawful purpose contribution to the unit of government: $ p z-,04) / Amount of lawful purpose contribution received: We are aware of the restrictions contained in Minnesota Statutes, section 349.12, subdivision 25(b)(6); and Minnesota Rules, part 7861.0120, subpart 1, s Signature of Chief Executive Officer (CEO)/ Print Name ' Y+Oh 1 q Jnc -e Date l— ZU ,- 6e) A Name of Government City of 4 M 2el/e3 tt Phone Number (40 ) 9w -AyDo Address -�-- 600 �;w1, ee,t 4 - Jr fwy ti City / 4t H0 hat ke3 )G State %%n V Zip ,Jc.4'0/y Check type of government: City County j Township School District No. of State of Minnesota, Department of , Division of United States, Department of , Division of • Other Government Entity - specify: / Amount of lawful purpose contribution received: $ 9j d go -1-1 Gi9 eU We are aware of the restrictions contained in Minnesota Statutes, section 349.12, subdivision 25(b)(6); and Minnesota Rules, part 7861.0120, subpart 5D(10). . e Signature of Government Agent 'Print Name t),‘„,..6.,_ L I SP.I"' YTitle / ed-tq 14,tMt+4tcf4- 1.244,.4_ y2 ZN("17 Date The information requested on this form will be used by the Gambling Control Board to determine compliance with Minnesota statutes and rules governing lawful gambling activities. All of the information supplied on this form will become public information when received by the Gambling Control Board. This form will be made available in alternative format (i.e. large print, Braille) upon request. If you use a TTY, you can call us by using the Minnesota Relay Service at 1- 800 - 627 -3529 and ask to place a call to (612) 639 -4000. (Rev. 1018/96)