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General Organization Name City License Number Month/Year Record of Charitable Contributions and Donations: Lawful Purpose Expenditures (Rev. 11/13) This form is used to document an organizations charitable contributions and donations for the purpose of being classified as 4c(3)(ii) property. Please read instructions before completing form. CR-DR Total of All A-Code Expenditures: $ Lawful Purpose Expenditures: List your charitable contributions and donations below. Please read instructions before completing. A list of qualifying A-code expenditures is located on the back of this form. Contributions and Donations Date of Check Check Number Check Made Out To: Description (Purpose) A Code Amount A- A- A- A- A- A- A- A- A- A- A- A- Sign Here Chief Executive Officer: Print Sign Date I declare that this form and all records of charitable contributions and donations contained therein, is correct and complete to the best of my knowledge and belief. Please provide this form, along with your application, to the county assessor. ---PAGE BREAK--- In order for your charitable contributions or donations to qualify, they must have been contributed towards one of the following purposes. These “purposes” are called A- code expenditures. You must identify each of your organization’s charitable contribu- tions and donations as one of the following A-code expenditures in the space provided on the form. (Qualifying A-codes include: A1 to A7, A10 to A15, and A19.) A-Codes A1 • to and by 501(c)(3) organizations • to and by 501(c)(4) festival organizations A2 • relieving the effects of poverty, home- lessness, or disability A3 • program for education, prevention, or treatment of problem gambling A4 • funding a public or private nonprofit education institution registered with or accredited by Minnesota or any other state A5 • scholarships A6 • recognition of military service (open to the public) • active military personnel in need A7 • for activities and facilities benefiting youth under age 21 Form CR-DR Instructions A10 • contributions to the United States, state of Minnesota, or any of its subdivisions or agencies or instrumentalities (except a direct contribution to a law enforcement or prosecutorial agency) • a fund administered and regulated by a city or county (for lawful purposes) A11 • to and by a nonprofit organization which is a church or a body of communicants A12 • water quality testing for public waters, provided that the MPCA has approved the project A13 • wildlife management project that benefits the public-at large, provided that the DNR has approved the project • costs related to grooming and maintain- ing snowmobile or all-terrain vehicle trails that are grant-in-aid trails, or other trails open to public use, provided that DNR has approved the project. • supplies and materials for safety training and education programs coordinated by the DNR A14 • conducting nutritional programs, food shelves, and congregate dining programs primarily for persons who are age 62 or older or disabled A15 • to community arts organizations or expenditures to fund arts programs in the community A19 • recognizing humanitarian service demon- strated through volunteerism or philan- thropy Date of check and check number - Enter the date the check was issued by the organiza- tion. For allowed electronic transfers, enter the date of the transfer. Enter the check number or electronic transfer confirmation number. Check made out to - Enter the name of the person, organization, or vendor to whom the check was made out to. This must match the payee as written on the check. For electronic transfers, this must match the payee infor- mation as shown on the bank statement. Description (purpose) - For each A-code expenditure, enter a brief description of the expenditure, such as honor guard, food- poverty, uniforms, medical bills, city 10% fund, etc. Use of Information The information on this form is required by Minnesota Statutes, section 273.13 to properly identify you and determine if you qualify for a special property tax classifica- tion. If you do not provide the required in- formation, your application may be delayed or denied. Your County Assessor may also ask for additional verification of qualifica- tions.