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• Minnesota Lawful Gambling LG555 Government Approval or Acknowledgment For Use of Gambling Funds (previously LG503 and LG265) (06/03) Organization Information (please print) Organization Name L_ o License Number WS- Address �O) 3� �.iiC..f /,55 4L) 55O/ ' Expenditure Description (attach additional sheets if necessary) 1. Amount of proposed lawful purpose expenditure $ OC .) 2. Check the appropriate expenditure category: XA. 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 that benefits the public at large with approval of the state agency that has authority over the project. Describe the proposed expenditure, including vendors. C. Grooming and maintaining snowmobile or all- terrain vehicle trails with approval by DNR. All trails must be open to public use. Describe the proposed expenditure, including vendors. Oath • I affirm that the contribution or expenditure, in accordance with Minnesota Rules 7861.0120, Subpart 5D(10), 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 . nagement project for which reimbursement is received from a unit of government, the reimburse- ment funjwn b de ted in our lawful gambling account and recorded on the LG1010 - Schedule C/D report. signature 65) -760- 4R74. l o// o3 Phone number Date Government Approval /Acknowledgment (Check one) By signature below, the representative of the unit of government: X, acknowledges the contribution in 2A above, which will not be used for a pension or retirement fund. _ approves the wildlife management project as described in 2B above (state agency only). _ approves the expenditure for grooming and maintaining snowmobile and /or all- terrain vehicle trails described in 2C above (DNR only). // Unit of Government CM' e.44- Lido //WET Address Print Name Signature Lj irk Keep this completed form attached to the LG1010 - Schedule C/D in your organization's records. You do not need to submit this form to the Gambling Control Board. 761,,,/ ept City / "i/ J;-li 6[ Phone number 7 222 -..mi, Statef' Zip1 Title W.( d2 1/ V /KFtl'z)L Date 7 / +cy / 05 This form will be made available in altemative format (Le. 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