89-652 WHITE - C�TV CLERK
PINK - FINANCE G I TY O A I NT PAU L Council �" �/��
CANARV - DEPARTMENT ��w (� �7 �(
BLUE - MAVOR File NO. r��r p1 _
Counc ' Resolution --�.
�� -'
Presented By ____
Referred To Committee: Date 3/3��
Out of Committee By Date
RESOLVED: That application (ID # 36 2) for renewal of a State Class B
Gambling License by Ha di g Area Hockey Association at the
Minnehaha Tavern, 733 hi e Bear Avenue, be and the same is
hereby approved/�ed
COUNCIL MEMBERS Requested by Department of:
Yeas Nays
Dimond
�ng [n Fa or
Goswitz
Rettinan O B
s�6e;n�� __ A gai n t Y
Sonnen
Wilson
� � 3 _ Form Appr ved by City Attorney
Adopted by Council: Date 2
Certified Pas e Council Se ar By ' 7/� �
By �
A►ppro y Mavor: Da Approved by Mayor for Submission to Council
By BY
PU�IlSf�D A P R 2 ? 19 9
, ; . �d�i'1�,��-
.
c��e o�r�ooMM�ee� ,. '
�' � . . , ���� ��� �. oflz52s
J. CarcF�edi
c,o�r,►cr ; ' o�r��r o�c,cn j r�,ro�ro�n�r;u,r►
' Ctirist ne Roz � — �:��� ��«�
� . �. --
� �*°� � � Caunci 1 Research
� .
�... . , 1. . � :
,,.,,, cm�nuw�v, �-
l . 1
Appli€ation fol^ renewal of a Sta ass B Gamb1ing Li.c�nse.
, ;
Notification D te: Hearing Datet 4-13-89
.
_ �na�s:c�aaw.u►�w�a �� r+eratr:
r�eta+wo aorwe�ar cm4 se�c�u�� w�w oRre aur �uvsr r�r+o.
aoNn�o co�saioN reo�s sc►+oo�eoapu
sru� c�R co�e+rssaN +�s�s �om.x�o.�oaFON _��o t x�+w� _��ooeo*
,DIBTWCr OOUNCIL � �� * � . ; - . ' ... . .
�' . �rYM11Cl1C011qpl0&�VE9. � � . - . .. ,. . �i � � . . � . .. � . � � � �` � �
.. .. ; . . . . .. I,-.. � - .. . � i . . . _ . � . . �. . � .
. . � . �, .. � . . � . . .. �I . .. . . � �
� . . � � . . � � - � . .i . .. i � . . . . . .- . . ._ . .
- . . � . . . . . . . _ . 'I . . . . . . . � . . , � . �I . . . . . , . ; ._ . . �
i
- . �. .. - , � , . . . .. _ .. .I � . . � � � . . . . . - . . � . � .. I . . . .
MMT�10�RaL�ll.Mlt1E.OI�POR'RNrTY .Whst,Whln.MIIMr.WhYl:
Don Sperr, on b�half of Harding A a ockey Assoeiatti�,�, requests City Council
_ approval of his�;application for r e 1 of .a State C1ass! B Gampling license at
the Minnehaha T vern, 733 White B r venue. . Proceeds f�m the sale of .pullt�bs _ _:
-: � are used to sup�ort youth .hockey. ;.
j
I -
� �.�. >: , , . ; . . : _ - :
Al1 fees and ap�lications have bee s bmitted. A1T 10� 4ontributior� p�yments
to the,: City Y�u h Fund,are;curr�nt
,
ca�au��r�e,.t�.na�sowao�►y i , . _. . .,. ',: ;.
'
If Council �appro' al is given, Hard ng rea Hockey will cohtinue to sell
. pull�abs a� the in:nehaha Tavern.
� � -
. ,
. . . .,. ; �,:
, . �
. �t,�nu►�s: � . c�,rs . . .
�
�
_ i
, i
_ ; .
i
� .
� � i �
NsronrRn�s: ,
; ,
�
�! : ��',.!^�ii ��S�c��'C�1 C211tEY
uau�s:
', t�lAR 31 i;89
. �,
,
; ,
� : _
�1i�1/.OF TIOlUPIMNqPAi.3: _ = s
S?'/11CB10LDERS(k.isU Poenwn(+.-.O) � i-wr.t.tESr�rz(vw�ty n��fsumwm �nryum�MS1
�'_
FlNAMClAL IMPACT �r�►a oma) sc�o r�n . worES:
o�►�a euoc�:
REVENUES GENEAATED ...................................................»..,....... , . ,
EXPENSES: .
Salaries/Fmge Ber�eflts.....................................................:..
EtWiPment............................................................................
�PP�� .................:. ,
. . ,. _
Caitracts for Serv�e............................................................. .
Otfier
PROFiT(LOSS) ....:...........................................................................
FIMIDING SOURCE FOR ANY LOSS(Neme and NraurK)
CAPfTAL IMPROYEM@IT BUD6ET:
` DESIQN COSTS................................................................................
_ ACQU�1►10N COSTS...............: _ _
.
CONSTRl7C7'I�1 GOS7S ............................•••.................................
TOTAL ............................:............................................-........................
SOURCE OF FUNDINfi(Name and Mwunt)
IMPACT ON BUDQET:
lUAOUI!IT(:URR2NTLY BUDLiETED.............................:. - , _
AMWIiT IN EXCESS OF CURRHlT BUD�iET......�.................... . , .
SOFJRGE OF AMOUNT OVER HUD�iET........................................
PROPER'T1(TAXES GEMERATED(LOSTI .........
NIPLF.1�!(TATION RESPON&BRIT1f:
.. OEPT/OFF7CE � DIVI�ION � FUND TIiLE . �
, �-BUDQET ACTIVITY NUMBER 8 TITI.E� � . . . � � .. ACTMTY MANAGER . . �. �. . ... -
HOW PERFORMANCE 1NN.L 9E IEA�IRED4:
PROCiRAM OBJECi1VE8: PROGRAM IND�ATORS iST YR. 2ND YR.
_ _ _ _
EVALt1A710N i�SPO1�J1Y:
pEq$pN DEVT. PMONE NO. AEPORT TO COF/NCIL OF ' DATE
FIRST QlIARTERLY
_ _ Y
DIVISION OF LICENSE AND PERMIT ADMINI T TION llATE 3 3C� � / 3 30 � �
• IN'TERDF.PARTMENTAL REVIEW CHECKLIST A.ppn rocessed/Received by
Lic Enf Aud
Applicant �bn S�✓1� Home Address l(g�� �rj,pp,,r ��pr� ��
Rusiness Iv'ame �r �ti p�Home Phone � � � �7 y / 7
Business Address i h n e I��,hli. T a P� ►'� Type of Licease(s) �.e n��A �� S�`tC.�
Business Phone 7 '� �.C'�1,��4. q ���iss � �,yl b��yl�i C�.1 (-Q�1'� S-e�
Public Hearing Date � /3 O License I.D. 4{ ��
at 9:00 a.m. in the Council Chambers,
3rd floor City Hall and Courthouse State Tax I.D. �C �'/�'
Uate Notice Sent; Dealer �� ���"
to Applicant 2 �
rederal I'irearms �� N��'
Pub.lic He�.iring
DATE II�SPE 'TI N
REVIEW VERFIED (CO U ER) CUMMENTS
A proved No A roved
�
Bldg I & D �
� � ,
Health Divn. '
��� �
�
Fire Dept. � �
I NI� f
! - f
Police Dept. I
License Divn. �
�� i ��
(
City Attorney �
� 3j � 61L
Date Received:
Site Plan �f�p ���
—� To Council Research � 31 ��
Lease or Letter G Date
from Landlord 3 3(� O
.s'•t. ':�i ' A:":� =w- �v+' s�i, ,�:� ; . .-°.s�e �.�z�,�e E;y'Sv,��u' �' +,. .� (� , .. h'n�`-t:•". -iP'i,'° a e � , � �:
�`� Charitable Gambling Control Board � � � �
' Rm N-475 Griggs-Midway Bldg. For Board Use Onry
1821 University Ave. Pa�d Amt:
St. Paul, MN 55104�383 *�� � - �k�. -
.
� , ,, . � ,
, �r:. x .�<:��612}642-0555�g '�:�l�`�'''�:�4�'��I�'� ,; y,; „����`�'���'��'' �^' '���a������.�{,:y�;,�,�,�, ,
�3 � GAMBLING LI EN E RENEWAL�APPUCATION � �" '�
LICENSE NUMBER: R-A1518-l13 /EFF. TE /AMOUNT OF FEE: •
1.Applicant—legal Name of Organization 2.Street Address
}fOC.tfT A�SOC NRHDT!I6 9REA ST P9Ul 1615 Opper Afton RC
3.City,State,Zip 4.County 5. Business Phone
St Paul, NN 55116 Ra�soy 612 1I1-4�91
.�. �
3� -: 6.Name of Chief Executroe Offic�r k � ,�- ���ti �� w � �` ,�. T_Buainess Phone � �
, � r�e Wt�o��tt �.�L�� p�.. _,;;,�:�- � �,��.���� g��}���, ci�.-� ::;��sc�„;;� ���
8.Name of T�reasurer or Person YVho Accounts for Revenues ���,�F��.^�w� .,tk:� �; ,� � �g�� ��.�' � �
.•
,
.:
�, . ,,
.
' for Alsan �x; ...< ;. . , �,.. �.� . -.
- � ' ' � �'i2t� 1if-1191� ,� `°'
•:: : , , . . • � �
��, 10.Name of Gambling Manager - , . <; ;<., . �Y 11.Bund Number a�� �� �•:- .42 Buainess Phone :: , � �.�
�
Sonald Sp�rr . 1PSl�12T9 '` ' 6�2 7)l-9�9I ` "
, ��
13. Name of Establishment Where Gambling Wiil Take Place 14.County 15.No.of Active Members
Minnehaha Tavern St Paul Aa�sey 12� �
16. Lessor Name 17. Monthy Rent: �
Ninnehaha Tavern _ f211 ,
18. If Bingo will be conducted with this license,please specity da an times of Bingo.
Days Times Da s Times Da� Times
".si 19. Has license ever been: :O Revoked Date: ❑ Suspended Date: O Denied Date: ' � , _.�;,,;:
��� 20.Have intemal controls been submitted previously? ; r �Yes ❑ No(If'No;attach copY) -„y k� ' �r :� �� ;`,' :
, 21.Has current lease been ftled with the�board? �6iJ Yes `❑ No(If'No;attach copy) ��':��"�? �"{ . ,��'�,� ..`°`•,`
. Has current sketch been filed with the board? < f I Yes , •O No(If°No,'attach copy) {
,
, . , _ �M
. - ._
� , .•Y; ,;� #- - � �IN �S AUTHORIZATION ..� � . .� � ��..r� - �i►'° �;�Ik�}�
By my sign, ure below,,Ipcal law enforcem n�officers or agents.of e re d are t�r authorized to enter u ao the site,a any tlme, bl�"
. bei � .. .:< , geejV °' - ,ai • �
�n�' obaenre t a b�` � forca„ttt��, ' i�. �:
. ,
i;��X� ,. ,�e ef� �,C3ambli `i�
, �,
iulfill s��� .
f9QU�fA�A[It8 Of CUIT@fl�Q8R1��N�@S 8�(8W ���i�` �` �g�."• . �y"� ,C x, � ..y �>>:i.; �n ,;�� �`�
. ., r., A� fi , .�,�f.s, a� y. t.ri �.
I hereby declare that: '� . �� ;� ' ,- ''. `�
.�,. 1�.I have read thls application and alt.information submitted to the d., , , -: a; •w.a;;,: ,:~:.. �„' :.•� a,�• •,1 : •„� ,,;,,,,;�a,- •k_.,�;,:
F. 2. All informatiori submitted is true,aocurate and complete; �' � a , a;
3. Ail other required information has been fully disclosed;
4. I am the chief executive officer of the organization;
5. I assume full responsibility for the fair and lawful operation of all ctivi es to be conductedJ
.� 6. I will familiarize myself with the Iaws of the State of Minnesota r ct g gambling and rules of the board and agree,if licensed,to abide by those
Iaws and rules, including amendments thereto. �
23.Official Legal Name of Organization Signatur hief tive Officer) Date Tttle
H-a��N�A��,� �o�..x�� ,�� ' ��/�. ,
t " �,,,, .a�;�,�, 'M , / � , ' ,.
s'- a.w ��
;,.. .... . , . . . .. .. . . . _. . , t,�;� ,,�:
ACKNOWLEDGEMENT OF OTI E OCAL GOVERNING BODY � '�
I hereby acknowledge receipt of a copy of this application.By ackno edg eipt,I admit having been served wtth n�ice that this applicatlon vnll ;
be reviewed by the Charitable Gambling Control Board and if approv by Board,will become effectivb.�days irom the date of receipt(noted
below), unless a resolution of the local governing body is passed whi sp ifically disallows such activity and a copy of that resolution is received by
the Charitable Gambling Control Board withir�Q days of the below n ted te.
24.City/County Name(Local Governing Body) '�-� ownship: If site is tocated within a township,please complete items 24
�� •_.,.' �_; ' -, �..k nd 25:
ignatur of`Person Receiving Application: 5. Signature of Person Receiving Application
�`` .�- �
le : Date,,A' eceived(this date begi�S�O day period) itle:
Y '. :�t 1-t±, :1_L�+.Y 1�1,�-�1� :;I�,a
of Person Deli've(ing;Application to Local Governing Body: ownship Name
--�'�/
0022-01 (5/8� .�' hite Copy—Board Canary—Applicant Pink—Local Governing Body
�
=�3�y�2
, . er ot sab,t Paw
O�psNtn�nt of ��tans��t Setvices
Oi�ri
. • 203 Cit�r Han
S� . nesots 36102•296S05d
: APPLI ON FOR LICENSE
CA8N CHECK CCA88 NO. R�new
� � � � , � � ' �) �.,r
. Date � �v t9 v '.
Cod�Np. TNN ot Lkens� pro �� 19"!To � 19�
i
o�J�!3 t- � - J� . �`J .
100 i n . G•� �'OC
' �4�1. N
�oo � �-'9 r r�,u G�.��, �,E?n!
100 BWin�q NanN
too �7� (.�.� h,1"> ,�f�,e �?-�.�-�
���y� Phene No.
tO0 ��, � �} �
G Lv /�'' � ���(t'
' 100 ~ Mafl to Addr�as Phone No.
� �.. '1'1� —�`f 11
to0 �'jr, ��-r yr�.T
Manap�HOwrNr•Nsm� ��
�� ��� � '���P� �-���; ��
. 100 A/�nipNKrwnN•Mom�Address Phcn�No.
ION A�Ikstblt fM � . yp .
o �� S-T� � ✓� ss��(,`.
;: � - � � . a s ww�,o.�...ua.saa ' nv coa./�. _
.. �� � �� . �.�z. . . ...� . �?=',;
_ - >. . . , � - . . �, - ..�:
",•UO�IIN Mqp�101 � �"� 8r ` �• ipiatw ol Appikanl.�-� , .
90f1d'
Con�p�r Nam� pppe�r Np, Expiration Date
�nsu
Con�pM�NanN pp�le�►Np, Expfration Date
Mi�n�sota Stat�Idei+tifiestton No Socisl Sacurity No
VN11C1�IMormstio�r . �
��� �t�Number
OthN'
� THIS IS A R C PT FOA APPLICATION �
. TMIS I$NOT A LICEN8E TO OPERATE.Your appllcafion for � will Nthsr b�qaMed a roiacted subject to the provisions ot the zoning
polnine�ana CanplNion of tM fnsp�etio�s b1r iM HNith, n.Zoninq sndla lie�ns�Insp�Ctors.
. �15.00 CHARGE F L RETURNED CHECKS
� 3���� �'� �
' Cit o Saint Paul
Department of Fi an e and Management Services
� Division of Lic ns and Permit Registration
INFORMATION RE UIRED WITH APPLICATION F R ERMIT TO SELL PULLTABS � TIPBOARDS IN SAI�T PAUL
(Class B Gambling License in Liquor Est bI shments - Renew)
1. Full and complete name of organiza io which is applying for license
� --,�-� •^ ; �� �. - `�
� �t �;1 �-�,. � i i
� � . � � - '� f JStC?l�
2. Address where games will be held 3 C.- i i�v L
umber Street City Zip
3. Name of manager signing this appli at on who will conduct, operate and manage
Gambling Games Date of Birth /;�� /7-,� ��
.
.-.
(a) Length of time manager has bee m mber of applicant organization � i.i���`h`�
) �' � --7_
4. Address of Manager 7. '� 1 � % ' i ? �. <5 I d �
Number Street City ' Zip
5. Day, dates, and hours this applica io is for
6. Is the applicant or organization o ga ized under the laws of the State of :QT?
7. Date of incorporation 9
8. Date when registered with the Stat o Minnesota /�-�/ � , � /
9. How long has organization been in xi tence? a p �/r A r2 S
10. How long has organization been in xi tence in St. Paul? ���/1=�iZS
�
11. What is the purpose of the orgaaiz ti n? � �c L��
12. Officers of applicant organization
�,
Name �� Name � .A�� �N!��-�I�
Address � � 7r.=- N� Address ,�L,� � L'Y�n1 %�� t��,�
Title�j��S ' DOB Title � '' C _� � DOB �� a'�
� r
�
vame �r�An� L i= � Name �[�,�C�y A� DL 5 t� �1
, � r� 1
Address �C � �f /'�/�r/v�F.i�t � Address / / 3 � ,( ) /=i-c_. �
� ,.,
Title � DOB Title ��1^ IZ �, DOB
13. Give names of officers, or any oth r ersons who a1"2 paid for ServiCes to the
organization.
Name - - Name � �
Address Address
Title Title
(Attach separ te sheet for additional names.)
14. Attached hereto is a list of names an addresses of all members of the organization.
15. In whose custody will organization s cords be kept?
Name `�� � Address ,b �-� L���ci� �t�lanr � ! 1
16. List all persons with the authorit to sign checks for dispersal of gambling proceeds:
r. l
Name � ��. _ � i - `� Name
Address � 7 � �' • h� ^ l j Address
Member of Member of
DOBI�, /� �� � Organization? DOB Organization?
Name � � '' Name -
,���
�ddress '���r= 1� Address
Member of Member of
DOB Organization? DOB Organization?
17. Have you read and do you thoroughly un erstand the provisions of all laws, ordinances,
and regulations governing the opera io of Charitable Gambling games?
18. Attached hereto on the form furnish d y the city of Saint Paul is a Financial Report
which itiemizes all receipts, expen es and disbursements of the applicant organiza-
tion, as we11 as all organizations ho have received funds for the preceding calendar
year which has been signed, prepare , nd verified by�---;, ," S�7_�jZ_
"� �� i . ^ �fJ � �' •-�
Address
who is the of the applicant organization.
Name
19. Will your organization's pulltab op ra ion be operated/managed solely by members of
your organization? yes no
20. Has your organization signed, or do s 't intend to sign, a consulting agreement or a
managerial agreement with any perso o company to assist your organization with the
pulltab sales and/or recording keep ng? yes no ��
It answer is yes, give the name and dd ess of the person and/or company contracted.
lvame - Address
tiame Address
If answer is yes, how will such a co su tant be paid? (percentage, flat fee, gambling
funds, general funds, etc.) Attach c py of said contract to this application.
21. Operator of premises where games wil b held:
.-. } -
� � �
tiame .� \ c� h �.i < <"``j. c �� G �
Business Address � � _� �J , - � '�-�� � T� �-�/�-
. . ..-,
Home Address -, `-1 ; :��� , .�. ,�� �'� `' ,^ , � , 1 ��t� .� , ',,
2•2, a) • Does your organization pay or i te to pay accounting fees out of gambling funds?
yes no
b) If you do pay accounting fees, o om will such fees be paid?
Name Address
DOB Member of Or nization?
c) How are the accounting fees ch rg out? (flat fee, hourly, etc.)
d) What do you anticipate will be yo average monthly deduction for accounting fees?
23. Amount of rent paid by applicant o ga ization for rent of the hall:
r,
,�� /
24. The proceeds of the games will be isb rsed after deducting prize layout costs and
operating expenses for the followi g p rposes and uses:
�
� t� �
25. Has the premises where the games a e t be held been certified for occupancy by the
City of Saint Paul?
26. Has your organization filed federa fo 990-T? If answer is yes, please attach
a copy with this application. If s r is no, explain why:
l " � " � � ; - _ ~
i •1 � � . i,_ � -�,. =.i ••� � ,
� :
Any changes desired by the applicant as ci tion may be made only with the consent of the
City Council.
-�A�,�nz��.��?��.� �+�.��E�� �,SS::�i/a�
Organization Name
ilate ��j--�h— 1S ! gY� —_�/ �=---
' Manage � charge of game %
/; /
,�
i Organization Preside r CEO
�/
Ci y of Saint Paul Pag� 1
Department f F nanee snd Mana;sment Setvieea
' Division of Lic sa aod Permit Admiaistsation
UNIP'OR!! IT E CAMIILINC FINANCIAL REPORT
uau � -.��i d y
-�
1. Nm� of Orgsnization � ^ '� � , '� r
2. Addres• vhere Charitabl• Ca�b ng s eondueted � ' -;~ �`•�. _ �r=;,,�� � 1 i: -�--_
3. R�pose Eor pssiod eoverin` � i t L9_ thsough !:�- �3 �--� 19_
6. Total numbsr o! days playsd
� � X� �^ i
5. Cro�� r�esipts fos abov� psri : ��,_�� � �-'1�
6. Cross p�isa payouts tor abo�v� sr (inelud� eaah ahort) ; �C�i � a!'� _�' U
7. N�t ree�ipts - lia� S siau� 1 � _ �7 /� ' �'�+�'S
8. Expsn�e� laeurrsd in conduet a op�ratin` �a�:
A. Gross va`es paid. Attach ork c list vieh _ 1 .7
nam��� addr�ss�s, tro�• v es� awber of hours S � �_'� � �`�
vorked� and avount paid ps ho s.
B. R.�c cot � �..ks : a I Lz�...�`_
r' �
C. Licensa fae. _ ,_,� �'� y 7 � J
D. Insurance s
E. Bond i 1 /�� � C� f�:
!. Di�hoaored cheeb aot rse srs �
C. Accouacia` Ea�psase = ��� ��
N. Emplor�r� l.I.C.A. : ���^-7 = � 9
r
I. Pulltab 'faa Paid to Dapu �at oi t�venw 3 7.�3_'i ; � �
J. ltinn. U.C. Tu :
E. i�d�ral txeis� hx i Seaqi : U ��� Q
L. Stata Caablin� Ta: s 1 J.'�� �c�
M. Mi�cellansou� Expan�s�. I ent f� t6s a�ount
�ad to vbo� paid.
i. i �g� . �� 7
2. s ��Jl.� �/L�
3. � � ')� �� / d
t. �
9. io c,i �p.n.., mrni. : a ��3� �'� � ��
l0. N�t IOCO�� - lina 7 dau• lia� 9 f � 7 G` y� � �j �
11. Ch�ckbook balaae• b��innins of er d t �,y/��)� � 7
12. Total of lin� 10 and 11 = �-�� ��� • � �
" � l3. Total eoatriDutiona (tro� atta �d orksA��t) 3 �C � �� • ! �
l4. Checkbook balaaes and of rsport ng sriod - _ �
lina l2 les� lina 13 = � y J �^� `-� �L.—
UNIFORM CHARIT Bl GAMBLING FINANCIAL REPORT
, LAWFUL PURPOSE CO TRIBUTIONS • WORKSHEET
�Line #13 - Tatal Lawful Purpose Co tributions. S ,.��-, �� � . �l
List below all checks writ en from qambling funds which are
charitable lawful purpose on ributions. The total dollar
amounts of these checks mu t tch the amaunt claimed in
line �13. Use additional he ts as necessary. ,
CHECK � DATE PAYEE CHECK AMOUN PURPOSE
1-- / l C I�� ��'r_' �l� � � �'
i. ��i� ; '.s � a a3� y �
/ L. � i�.�
2. �o� � 1� /� �a+�Dl�v1� /� 1'�- oZDOv , o c� f ` �/
� 3,�O(s , L'� t.� -
s. �, s , i,a � ` ,
L �333 � � �,
�' L � I Y u J- ,5 �-� " �, „
4. � S^ a� � fad�,, ac tc % � lMl=
I�A`?�:•,i c� �1 �=',�,� �� I /
s. � L, � a� � ia�o� no
�, � '
6. �� a a> > 7 .. � i��� � �
r-, , � , �.�
�-� � �^ c'- � � y ���� , � ;-_. ;��,���-=-
�. �� � � � � �e���. �,r
�'�/-11��INL-�- !
8. �._7 C:� -3�' � � -, � � %�7- � �
� ^ % l� v
9. � 9 --► �; c � i y d �- s �, �^
� cr;� �y i n�.
a�p0, C,i=� /
io. �, � a y-a � N A2�j�t� � �►-
Z 1. �p �o� � � C-i � y O l" S � � rl r �.- j �7 ' f �
� � �� �, � f6�'� � o
12. ? � � � /� I � 7�. 3d .
�, J�I 't t ' " �
13. `7 � � .
TOTAL CHEC A UNT b I I I�b,p I
NOTE: These expenditures will be pro id d to Council hiembers at your Council hearing.
Be sure that your financial re or is complete and accurate.
N � r � � �
� � _
r � � i w + d � � •�i a e �
� ^ �
� ; � ` � ± ; � � ` ��
a
� � � + �..�..�.q. f O ♦ � s
� s i � .� � •� � � � � � .
f � � v ^ ^ � � ���� � � 2 � � �
� w
'� s _ �'. — {- r : � y � s
� � • � It �Z w f ~ a
n � s � �
�V � �.. + j S i O � j = �� �7 �
r � � J w • ! + � � �� � .��r� � ! � !
r � • � w j } "� �� � L w • • 4 �
! 1 � 7 r w • � ! • �1'L'� ���� r � 1
• � r � T� Cn�- °.? t 1� ♦
� : s e a` . � ��� t � ; � � •
.. a
� 1 • n ��p �
• s • � o C��. � 2
• • i � {bR C� � � s
• � � � ! \ I i�C, .�y- � ;
!} r w . � �{d=y.; � � i
i- .�. }^� •
if t
� w�� �n �
s �'� �� J � �
� �� � �i
J � r� . i I
J y ' i � �
�� I
UNIFORM CHARITAB MBIING FIyANCIAL REPORT
� . LAWFUL PURPOSE C TR BUTIONS - WORKSHEET
. ` , -,3
Line #13 - Total Lawful Purpose C tr butions. S �� (_`, 7� . I �
list below all checks writte f gambling funds which are
charitable lawful purpose co ri utions. The total dollar
amounts of these checks must at h the amount ciaimed in
line �13. Use additional sh ts as necessary. ,
� CHECK � OATE PAYEE CHECK AMOUN PURPOSE
, r7
�. ��a ► � y �, F y � � s�;, �- �,3:��
^ �� �� �� ' J36�3 �
2. �3 y �- 1 � �
,� �r „ �1 } 9a� o -
3. � �3 ic S ht AR��n�G-A ►Zf= }' �.3��o Dt� � �� ;��r
4. �7.S � /0-'� �
, � 3s^a,�o
1 c ,'j� � r S �, ► �,
/ , � �
5.� �- � !� >t ,r � /C� �� S � `�
6. 7 � y ��'� ��.,�,o, �c�, i `- i= i.�.�=
� , A r`Z �
�. �� �y i��� �� i N�.� ���- �
a.
9. .
10.
11.
12. ' . .
13. � � �
TOTAL CNECK A NT E G� ��1 �
NOTE: These expenditures Nill be prov de to Council Members at your Council hearing.
Be sure that yvur financial rep rt is complete and accurate.
_ � . � • •
' -♦ � • •r � � � '' � i > �i '' �
� v .� � .�i ! . 'O� .�. .. � w ` +�
� � � .r /� {.t; • � ♦ 0 y1
� 1 .�
•
� i : e � ; = r + • ' � 'as
� 3 � � %� r �♦ v � ••
'� = � � � ! � e � � � �K � S � 7� O
� • � � � r •�.. � �{ :, .�'7:(� � • 1 r ` , .
! . � .'� � J � MO • �} ,` ...� f ^ � � � � �
�{ .J s .� • • w > �a
•1� � _ � � � � � i � `� .
A(�� ! . � � O � ��' � � � '�
�{�'. J • � • " 7 �"A -1 � v�r � � �
� +��' w ! ! r �'� � A sn_ ? � A � � 1
i � � � �
� `' � � � w + a =�3 : �� i '� � � f� �
� � i� s s �
,li' a i � � ? + j;T� n � a '� • f g �
• � � w •�i �;77 • 1 w i � i
�, ♦ 7 '
►
�; = w ! �' I `��� � ��_ � ; ;
:�` = � O w,, i� �� � = a
� �. 4:� �n � +
� ' a� s� 'O w
.
' . } i 3 p �• i I
� �.
v' s� I � + �
� y