Laserfiche WebLink
City of Delano <br />Local Gaming Entity Information <br />Name of Gaming Entity Submitted by Title Phone No. <br />Street City State Zip Code <br />Financial Information, 10% Contribution Fund <br />Attach a copy of your annual financial statement for calendar year__^ LGlOlO, and LG503, <br />a. Fund Balance-Beginning of Calendar Year 2_ ___________________ <br />Amount Collected (revenues) ___________________ <br />Cost of Goods Sold ___________________ <br />Allowable Expenses ___________________ <br />Net Profit for Calendar Year 2__ ___________________ <br />Fund Balance End of Year <br />b. <br />c. <br />d. <br />e. <br />f. <br />g- <br />h. <br />Lawful Purposes Expenditures <br />lC-% of Net Profit {10% of line e) <br />(Please make check payable to the CITY OF DELANO, P O Box 108, Delano, MN 55328 <br />Allowable Expenditures (line d • attach additional sheets if needed) <br />Date Payee Type of Allowable Expenditure Amount <br />Lawftil Purposes Expenditures (lineg • attach additional sheets if needed) <br />Date Payee Lawful Ptirpose Expenditure Amount <br />Certification <br />• I am the aforementioned organization ’s gambling manager and the official responsible for the <br />finnncial reporting of the restricted fund. <br />• I have reviewed the information contained in this report and certify that the above reported <br />revenues, expenditures, and fund balance reflect the activity of the fund during the calendar year. <br />• I am aware of restrictions under Minnesota state law on expenditures from this fund and certify <br />that the direct expenditures meet the definition of lawful purpose expenditures or are for police fire <br />and other emergency or public safety-related services, equipment, and training, excluding pension <br />obligations, and are accounted for in a manner consistent with generally accepted accounting <br />principals. <br />• I declare that all information on this form is true, correct, and complete. <br />Signature of Responsible Organization Manager Title Date Phone <br />Signature of Preparer Title Date Phone <br />Contact Person Title Date Phone <br />'This form must be completed and mailed by April 30,2001 to: City of Delano, PO <br />Box 108, Delano, MN 58328 Attn: City Administrator. 612-972-0550 or 612-072-6174 <br />C \KitU)ck\FOR.MS\GAMlXGlO DOC 1 <br />1