Lg555 Form

12/13 Minnesota Lawful Gambling LG555 Government Approval or Acknowledgment For Use of Gambling Funds 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 Address 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. 83 and 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. NO FINANCIAL OR OTHER BENEFIT I affirm that the contribution or expenditure does not result in any monetary economic financial or material benefit to our organization in compliance with Minnesota Rules 7861. 0320 Subpart 17C. FOR DNR-RELATED PROJECTS I affirm that when lawful gambling funds are used for grooming and maintaining snowmobile or 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. FOR SURFACE WATER QUALITY TESTING I affirm that MPCA guidance has been consulted in developing the monitoring plan 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.