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Minnesota Lawful Gambling LG555 Government Approval or Acknowledgment For Use of Gambling Funds 6/05 Organization Information (please print) Organization Name L a at es- ftiti x(l Cifii V FV (?'o S ( 6563 LicenseNumber Address -78 Pri Expenditure Description (attach additional sheets if necessary) 1. Amount of proposed lawful purpose expenditure 2. Check the appropriate expenditure category: 14-1. Contribution to a unit of government - United States, state of Minnesota, or any of its subdivisions, agencies, or instrumentalities. NOTE: A contribution may not be made directly to a law enforcement or prosecutorial agency, such as a police department, county sheriff, or county attorney. B. A wildlife management project or activity that benefits the public at large with approval of the DNR Describe the proposed expenditure, including vendors. s4 oo C. Grooming and maintaining snowmobile or all- terrain vehicle trails established under Minnesota Statute 84.83 and 84.927, including purchase or lease of equipment, with approval by DNR. All trails must be open to public use. Describe the proposed expenditure, including vendors. _ D. Supplies and materials for safety training and educational programs coordinated by the DNR, including the Enforcement Division. Describe the proposed expenditure, including vendors. Oath • I affirm that the contribution or expenditure, in compliance with Minnesota Rules 7861.0120, Subpart 5D(5), does not result in any net monetary gain or other pecuniary benefit to our organization. • I affirm that when lawful gambling funds are used for grooming and maintaining snowmobile or all- terrain vehicle trails or for any wildlife management project for which reimbursement is received from a unit of government, the reimburse- ment funds must be deposited in our lawful gambling account and recorded on the LG1010 - Schedule C/D report. Chief executive officer's signature / / Daytime phone number Date Government Approval /Acknowledgment (Che k one) By signature below, the representative of the unit of government: acknowledges the contribution in 2A above, which will not be used for a pension or retirement fund. _ approves the wildlife management project or activity as described in 2B above (DNR only). approves the grooming and maintaining of snowmobile and /or all- terrain vehicle trails described in 2C above (DNR only). _approves the supplies and materials for DNR safety training and educational programs described in 2D above (DNR only) / / UnitofGovemment (2, �0 P h / /I D L?,fJe 5 Phone number` .- 79"X — ,x.300 Address G YO /� w Yl `etjf�p kt.. city L. /ti• 4 C3 state M zip ccQ l� j I° PrintNamea: ! kIt aVlVie �� (rT'� 1 Title e t-hi 1. l e rk Date D / / 04.. Ke4 this completed for attached to the LG1010 Schedule C/D in your organization's records. You do of need to submit this form to the Gambling Control Board. This form will be made available in altemative format (i.e. large print, Braille) upon request. If you use a TTY, call us by using the Minnesota Relay Service and ask to place a call to 651 - 639 -4000. The information requested on this form will become public information, when requested by the Board, and will be used to determine your compliance with Minnesota statutes and rules goveming lawful gambling activities. For additional information, check our web site at www.gcb.state.mn.us