Lg555 Form – Fill Out and Use

LG555GovernmentApprovalorAcknowledgmentForUseofGamblingFunds

Keep this completed form attached to the Schedule C in your organization's records.

You do not need to submit this form to the Gambling Control Board or the Department of Revenue.

Organization and Expenditure Information (attach additional sheets if necessary)

Organization name _______________________________________________________ License number ____________________

Address _________________________________________________________________________________________________

1.$ ________________ Amount of proposed lawful purpose expenditure

2.Check one expenditure category.

___ A. 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. Wildlife management project or activity that benefits the public at large, with approval by the DNR

___ C. Grooming and maintaining snowmobile or all-terrain vehicle trails established under Minnesota Statute

84.83and 84.927, including purchase or lease of equipment, with approval by DNR. All trails must be

open to public use.

___ D. Supplies and materials for safety training and educational programs coordinated by the DNR, including the Enforcement Division.

___ E. Citizen monitoring of surface water quality testing for public waters by individuals or nongovernmental organizations, with Minnesota Pollution Control Agency (MPCA) guidance on monitoring procedures, quality assurance protocols, and data management, providing that data is submitted to the PCA.

3.Describe the proposed expenditure, including vendors.

________________________________________________________________________________________

________________________________________________________________________________________

•NOFINANCIALOROTHERBENEFIT: Iaffirmthatthecontributionorexpendituredoesnotresultinanymonetary,economic, financial,ormaterialbenefittoourorganization,incompliancewithMinnesotaRules7861.0320,Subpart17C.

•FORDNR-RELATEDPROJECTS: Iaffirmthatwhenlawfulgamblingfundsareusedforgroomingandmaintainingsnowmobileor all-terrain vehicle trails or for any wildlife management project for which reimbursement is received from a unit of government, the reimbursement funds must be deposited in our lawful gambling account and recorded on the Schedule C report.

•FORSURFACEWATERQUALITYTESTING: IaffirmthatMPCAguidancehasbeenconsultedindevelopingthemonitoringplan

and that the data collected will be submitted to the MPCA. Send form for signature to: Manager, Water Monitoring Section, Minnesota Pollution Control Agency, 520 Lafayette Road North, St. Paul, MN 55155. Website is www.pca.state.mn.us.

___________________________________________________	__________________________ _______/_______/_______
Chief executive officer's signature	Daytime phone number	Date

Print name ___________________________________________

Government Approval/Acknowledgment

Check one. By signature below, the representative of the unit of government:

____Government - acknowledges the contribution which will not be used for a pension or retirement fund.

____Wildlife DNR - approves the wildlife management project or activity.

____Trails DNR - approves the grooming/maintaining of snowmobile and/or all-terrain vehicle trails.

____Safety training DNR - approves the supplies/materials for DNR safety training and educational programs.

____Water quality testing - MPCA approves the surface water quality testing project.

Unit of Government __________________________________________________________ Phone number ____________________

Address_________________________________________ City __________________________ State ______ Zip ______________

Print Name_____________________________________________________ Title _________________________________________

Signature __________________________________________________________________ Date _________/_______/_______

Questions? Contact the Gambling Control Board at 651-539-1900. This form will be made available in alternative format (i.e. large print, Braille) upon request. 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 governing lawful gambling activities.