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LG$03 <br /> <br /> Mirtnesota Lawful Gambling <br />Request by a Government to Spend Gambling Funds <br /> <br />Name ol Govemmeni ~ues~ng Fun~ ................... <br /> I Phone Number <br /> <br />Address Ci~ S~ ~p Co~ <br /> <br />Check ~pe of government making request: <br /> <br /> ~C~ ~ ~unty ~ Township ~ School Di~H~ No._ of <br /> ~ State of Minnesota, Depa~ment of , Division of <br /> ~ UnEed Stat~, Depa~me~ of , Division of <br /> ~ ~her Govemment~ Enti~' - spe~ <br /> <br />:~.~.::~ zz~.~[U ".'.' · ~:~:~:~-:~<:~:~>~>>>~<:::>~J~::~::~:~55~:~<-~>~`~:~:~:~:~:~:~:~:~:~:~ .-'.:.-'.'..-. --.,.-~..;-....~.-x-:.:-:.>~:~?~:.:.~:~... <br /> <br />O~,za,on Phone Numar '~n"' Nu~;; ..... "'""'""'"'*"' <br /> <br />Address <br /> Ci~ S~te ~p ~e <br /> <br /> ~ ~ "'"' ' ~' ~'" .......... '"" .......... · f."'.Y. <'~ ".' ','r' ',?"m';<'''x~'~'':':~:':':'~;':<~':'~'~:~::-'~:f<:::.-;::.:,.~.::~::.::~.',, .~?.:. '~:~:~:~'<~>~.:~:~:~;~:~:g~:~;~:~:::::-::~>~>;:~ ~8~:~%~:~::~:~:A~:~:~:~.'.~F <br />~ne .___ve-n~ government r~ues~ la~ul g~bhng profis for ~e following pu~se: <br />[explain expend~ure - a~a~ a~d~ional sheets ~ n~essa~. I Amount J <br /> <br />By completing and signing this form, the government's aoent confirms that the requested funds will be spent for a lawful <br />purpose. This request expires one year from the date b~low a~d rnay be renewed at the request of the Iocal goveming body. <br />Slgn~lur of go~mmen! agent Title Daze . <br /> <br /> Pgn~ name / <br /> <br /> / <br /> Use of Form: <br />1. If an organization wishes to contribute gambling funds to a governing body, the governing body must complete this form. <br />2. AoorovaJ of the Gambllnq Control Board Is not requlred <br />3. The form should be kept on file by the licensed organization. <br />4. ,~ttach a Co~¥ of this form to your Schedule C ~epor~ for the month In which the funds are spent, <br /> <br /> <br />