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MINNESOTA LAWFUL GAMBLING <br />LG22O Application for Exempt Permit LLILT <br />Page 1 of 2 <br />An exempt permit may be issued to a nonprofit <br />organization that:. conducts lawful gambling on five or fewer days, and. awards less than $50,000 in prizes during a calendar <br />year. <br />If total raffle prize value for the calendar year will be <br />$1,500 or less, contact the Licensing Specialist assigned to <br />your county by calling 651-539-1900. <br />Application Fee (non-refundable) <br />Applications are processed in the order received. If the application <br />is postmarked or received 30 days or more before the event, the <br />application fee is $1OO; otherwise the fee is $15O. <br />Due to the high volume of exempt applications, payment of <br />additional fees prior to 30 days before your event will not expedite <br />service, nor are telephone requests for expedited service accepted. <br />ORGANIZATION I N FORMATION <br />Organization <br />Name:Ducks Unlimited North Suburban Chapter 239 <br />Previous Gambling <br />Permit Number:x-0331S19-013 <br />Minnesota Tax ID Federal Employer ID <br />Number (FEIN), if any:Number, if any 36-3766069 <br />Mailing Address 1320 Amble Road <br />City Arden Hills State: MN Zip: 55112 County Ramsey <br />Name of Chief Executive Officer (CEO). Peter Belsito <br />CEO Daytime phone: 651-242-3889 CEO Emait : peter.g.belsito@gmail.com <br />(permit will be emailed to this email address unless otherwise indicated below) <br />Email permit to (if other than the CEO) <br />NONPROFIT STATUS <br />Type of Nonprofit Organization (check one) <br />Fraternal l-l R"tigiou.Veterans Other Nonprofi t Organization <br />Attach a copy of 9!!g of the following showing proof of nonprofit status: <br />(DO NOT attach a sales tax exempt status or federal employer ID number, as they are not proof of nonprofit status.) <br />A current calendar year Certificate of Good Standing <br />Don't have a copy? Obtain this certificate from: <br />MN Secretary of State, Business Services Division Secretary of State website, phone numbers: <br />50 Empire Drive, Suite 100 www.sos.state.mn.us <br />St. Paul, MN 55103 651-296-2803, or toll free 1-877-55L-6767 <br />IRS income tax exemption (5O1(c)) letter in your organization's name <br />Don't have a copy? To obtain a copy of your federal income tax exempt letter, have an organization officer contact the <br />IRS toll free at 1-877-829-5500. <br />IRS - Affiliate of national, statewide, or international parent nonprofit organization (charter) <br />If your organization falls under a parent organization, attach copies of both of the following: <br />1. IRS letter showing your parent organization is a nonprpfit 501(c) organization with a group ruling; and2. the charter or letter from your parent organization recognizing your organization as a subordinate. <br />GAMBLING PREMISES INFORMATION <br />Name of premises where the gambling event will be conducted <br />Biq 10(for raffles, list the site where the drawing will take place) <br />Physical Address (do not use P.O. box)4703 N Hwv 10. Arden Hills. MN. 55112 <br />Check one <br />City Arden Hills zip 55112 County <br />County <br />Ramsey <br />Township:zip <br />Date(s) of activity (for raffles, indicate the date of the drawing):Aoril4.2020 <br />Check each type of gambling activity that your organization will conduct: <br />Bingo Paddlewheels Pull-Tabs Tipboards Raffie <br />Gambling equipment for bingo paper, bingo boards, raffle boards, paddlewheels, pull-tabs, and tipboards must be obtained <br />from a distributor licensed by the Minnesota Gambling Control Board. EXCEPTION: Bingo hard cards and bingo ball selection <br />devices may be borrowed from another organization authorized to conduct bingo. To find a licensed distributor, go to <br />www.mn.gov/gcb and click on Distributorc under the List of Lien*es tab, or call 651-539-1900.