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Minnesota Lawful Gambling <br />LG510 City or County Annual Report, 10% Contribution Fund <br />Page 1 of 2 <br />5A)1 <br />Local Unit of Government Infoimation <br />Name of city or county Division I <br />Street ^ City state <br />MN <br />Zip code <br />Caleodar year .Contnbutk>n rate .% (indicate the percentage rate being imposed. The rate <br />cannot exceed ten percent per year of net profits. Net profits are gross profits less amount <br />expended for allowable expenses and paid in taxes assessed on lawful gambling.) <br />a. Fund balance, if any. from previous year $. <br />(If none, enter "(T) <br />b. Add amount coRected (revenues) during the <br />year from all organizations <br />c. Subtotal (add lines a and b) s <br />d. Minus total expenditures for calendar year <br />made from the fund <br />e. Fund balance - end of year (subtract <br />lined from linec) <br />If you have a positive end>of*year fund bai> <br />ance, give a brief explanation of why the bal>< <br />ance will be maintained: <br />Expenditures <br />eaat <br />Lawful Purpose Expenditure <br />Code fsea attachadi AirouPt <br />S. <br />S. <br />s. <br />$. <br />f. Subtotal from other page(s) %, <br />g. Total amount of expenditufes (enter on intd): $. <br />Certification <br />• I am the cRy or county offlcisl responsbie fbr the financial reporting of the restricted fUnd <br />• I have reviswed the infoimation contained in this report aiKl certiy that Ihe above reported revenues, expenditures, and <br />fUnd balance reflect the activity of the hind during this calendar year. <br />• I am aware of restrictions under Minnesota sUta law on expendlures from bis fund and certify that the direct expenditures meet the defnition <br />lawfril purpose expenditures or are for pofee. fire, and other emergency or pubic safety-related services, equipment, and training, excludir <br />pension obigations. and are accounted for In a manner consistent wlh generaly accept^ accounting principles. <br />• I declare that al information on this form is true. correcL and complete. <br />Signature of responsible city or county official Title <br />/ <br />Date <br />/ <br />- /_____ <br />/ <br />Signature of preparer Trtle Date <br />// <br />Contact person Title Date <br />Phone number, including area code _ , <br />This form must bs compisttd and mailed by <br />March 15 to: <br />Gambling Control Board <br />Suite 300 South <br />1711 West County Road B <br />Roseville. MN 55113 <br />Questions on bis form should be directed to be Gambfng Control Board at 651* <br />639-4(X)0. Hearing impaired individuali using a TTY may cal be Vnnesota Relay <br />Service at 1-600-627-3529. Thb pubicMion wi be made avalabie n alemabe <br />format (Le. large prinL Braie) upon request The information requested on bis form <br />wi become pubic bformaticn when received by be Board, and w6 be used to <br />determine compiance wih Minnesota statutes and rules governing bwA.1 <br />gambing actMBes.