5.1. SR 07-19-2004 - Laserfiche WebLink

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Form SC-04 ELK RIVER / Page 5 This Schedule must be fully completed, certified by the relief association officers, forwarded to the municipal clerk on or before August 1, 2004 and submitted to the State Auditor's Office to be eligible for state fire aid. OFFICER CERTIFICATION We, the officers of the Elk River Relief Association, certify that this Schedule was prepared under Minn. Stat. § 69.772 and that the annual benefit level was established according to the average amount of available financing. We further certify that based on the financial requirements of the Relief Association's Special Fund for the 2004 calendar year, the required 2005 municipal contribution is $ 0. If the bylaws of the Relief Association changed in 2004, we have attached a copy of the amendment or updated bylaws. We have also enclosed a copy of the municipal ratification of this amendment if required under Minn. Stat. § 69.772, subd. 6. Signature of President Print Name Date Signature of Secretary Print Name Date Signature of Treasurer Print Name Date MUNICIPAL CLERK CERTIFICATION (For relief associations affiliated with municipal fire departments only.) I am the municipal clerk of I received on , the completed Schedule from the Elk River Relief Association. I have reviewed Lines 14 and 21 of the Schedule. If either Line 14 or Line 21 show a required municipal contribution, I certify that I will advise the governing municipal body of any required municipal contribution at its next regularly scheduled meeting. Signature of Municipal Clerk Print Name Date ( ) Business Telephone Please retain a copy of the Schedule for your records and submit the signed original to: State Auditor's Office, Pension Division, 525 Park Street, Suite 500, Saint Paul, MN 55103. Fax: 651-282-5298. Telephone: 651-282-6110.