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<br />LG503 <br />(Rrt.l twI901 <br /> <br />Minnesota Lawful Gambling <br />Request by a Government to Spend Gambling Funds <br /> <br />e <br /> <br />:G2'~trtmertE[frtf&httfffiart]I@~)ili~B]:@:@m@@W;WI;IW!ml'~;;H;mm;:;:;@lfmmrWi1BItWf@~:}1i.lWJfmHUmi@;;;@f%:g@mllfu0mi <br />Name of Government Requesting Funds Phone Number <br />CITY OF ELK RIVER (612)441-7420 <br /> <br />Address <br />13965 Orono Parkway <br /> <br />City <br />Elk River <br /> <br />State <br /> <br />Zip Code <br />55330 <br /> <br />MN <br /> <br />Check type of government making request: <br /> <br />Wcity <br /> <br />o County <br /> <br />o Township <br /> <br />o School District No. <br /> <br />of <br /> <br />o State of Minnesota, Department of <br /> <br />. Division of <br /> <br />o United States. Department of <br />o Other Governmental Entity - specify <br /> <br />, Division of <br /> <br />pIfgarm7ffilfmfifi.r6tifffitl6mt~J1~tlw1iilill;rHf:*1:111fii~mi:ig;mil;rfW;JfIII];:1;fi11itW@lftt%f,~li.iN!fl~\li;;~ijtlf~;Jftlr;@mt.rg\\~;WJf@:ll <br /> <br />Organization Phone Number Ucense Number <br /> <br />Address <br /> <br />City <br /> <br />Slate <br /> <br />Zip code <br /> <br /> <br />Amount requested <br />$ 860.00 <br />Two 15' X 25' fla~s for the downtown Jackson Square flagpole. <br /> <br />e <br /> <br />By completing and signing this form, the govemmenrs agent confirms that the requested funds will be spent for a lawful <br />purpose. This request expires one year from the date below arid may be renewed at the request of the local goveming body. <br /> <br />TIlle <br /> <br /> <br />Cit Clerk <br /> <br /> <br />Sandra A. Thackeray <br /> <br />Usa 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. Aooroval of the Gamblfna Control Board Is not reaulred. <br />3. The form should be kept on file by the licensed organization. <br />4. Attach a coov of this form to vour Schedule C Reoort for the month In which the funds are soent. <br /> <br />e <br />