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0 3 -173 <br />• <br />• <br />Minnesota Lawful Gambling <br />LG555 Government Approval or Acknowledgment <br />For Use of Gambling Funds (previously LG503 and LG265) <br />(02/03) <br />Organization Information (please print) <br />Organization Name License Number <br />Address <br />Expenditure Description (attach additional sheets if necessary) <br />1. Amount of proposed lawful purpose expenditure <br />2. Check the appropriate expenditure category: <br />A. Contribution to a unit of government - United States, state of Minnesota, or any of its subdivisions, <br />agencies, or instrumentalities. NOTE: A contribution may not be made directly to a law enforcement or <br />prosecutorial agency, such as a police department, county sheriff, or county attorney. <br />B. A wildlife management project that benefits the public at large with approval of the state agency that <br />has authority over the project. <br />Describe the proposed expenditure, including vendors. <br />— C. Grooming and maintaining snowmobile or ail- terrain vehicle trails with approval by DNR. <br />All trails must be open to public use. <br />Describe the proposed expenditure, including vendors. <br />Oath <br />• I affirm that the contribution or expenditure, in accordance with Minnesota Rule 7861.0120, subpart 5D(10), does not <br />result in any net monetary gain or other pecuniary benefit to our organization. <br />• I affirm that when lawful gambling funds are used for grooming and maintaining snowmobile or all- terrain vehicle trails <br />or for any wildlife management project for which reimbursement is received from a unit of government, the reimburse- <br />ment funds must be deposited in our lawful gambling account and recorded on the LG1010 - Schedule C/D report. <br />Chief executive officer's signature <br />Phone number <br />Date <br />Government Approval /Acknowledgment <br />(Check one) By signature below, the representative of the unit of government: <br />acknowledges the contribution in 2A above, which will not be used for a pension or retirement fund. <br />_ approves the wildlife management project as described above in 2B (state agency only) <br />approves the expenditure for grooming and maintaining snowmobile and /or all- terrain vehicle trails described <br />above in 2C (DNR only) <br />Unit of Government <br />Address City <br />Print Name <br />Signature <br />Phone number <br />Title <br />State Zip <br />Date <br />/ / <br />Keep this completed form attached to the LG 1010 <br />- Schedule C/D in your organization's records. <br />This form will be made available in alternative format (i.e. <br />large print, Braille) upon request. If you use a TTY, you can <br />call us by using the Minnesota Relay Service and ask to <br />place a call to 651 - 639 -4000. The information requested on <br />this form will become public information, when requested by <br />the Board, and will be used to determine your compliance <br />with Minnesota statutes and rules goveming lawful gambling <br />activities. For additional information, check our web site at <br />ww.gcb.state.mn.us <br />