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LG503 <br />(R•v.10/B/DOt <br />Minnesota Lawful Gambling <br />Request by a Government to Spend Gambling Funds <br />. . �t�errirrc .rt rg"ormat: con .':. <br />Name of Government Requesting Funds <br />City of Lino Lakes <br />Phone Number <br />(651) 982-2400 <br />Address <br />600 Town Center Parkway <br />City <br />Lino Lakes <br />State <br />MN <br />Zip Code <br />55014 <br />Check type of government making request: <br />City <br />County <br />Township <br />State of Minnesota, Department of <br />United States, Department of <br />Other Governmental Entity - specify <br />vegan L2 aon.lrt.'orra:z pan <br />Organization <br />GWir, C .r -- L. Ex I// til. 655' 3 <br />Address <br />7 t,-4 JOKE <br /><•.• ete•uesh... <br />School District No. of <br />, Division of <br />, Division of <br />City <br />Phone Number <br />(51 ) 5L —;3f3 <br />State <br />License Number <br />Zip code <br />*55.'/ 11 <br />he a••ve-named government requests la u gam• ing pro its or t <br />(explain expenditure - attach additional sheets if necessary. <br />,_.7 <br />e o lowing purpose: <br />Amount requested <br />$C'C„ <br />By completing and -signing this form, the government's agent confirms that the requested funds will be spent for a lawful <br />purpose. This request expires one year from the date below and may be renewed at the request of the local governing body. <br />grire of government agent <br />;fi n M, <br />Print <br />- 3, K_ <br />Title <br />Date <br />Use of Form: <br />1. If an organization wishes to contribute gambling funds to a goveming body, the governing body must complete this form. <br />2. Approval of the Gambllna Control Board Is not reaulred, <br />3. The form should be kept on file by the licensed organization. <br />— 4. Attach a copy of this for <br />11 • • <br />• 1 =•• : <br />1e 11.1 . 1 • 1 1 1= l 1•• '•=/ <br />