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Attachment A MINNESOTA LAWFUL GAMBLING LG220 Application for Exempt Permit 4/22 Page 1 of 4 An exempt permit may be issued to a nonprofit Application Fee (non-refundable) organization that: Applications are processed in the order received. If the application • conducts lawful gambling on five or fewer days, and is postmarked or received 30 days or more before the event, the • awards less than $50,000 in prizes during a calendar application fee is $100; otherwise the fee is $150. year. If total raffle prize value for the calendar year will be Due to the high volume of exempt applications, payment of $1,500 or less, contact the Licensing Specialist assigned to additional fees prior to 30 days before your event will not expedite your county by calling 651-539-1900. service, nor are telephone requests for expedited service accepted. ORGANIZATION INFORMATION Organization Previous Gambling Name: Ducks Unlimited North Suburban Chapter 239 Permit Number: X- 03315-23-019 Minnesota Tax ID Federal Employer ID Number, if any: Number (FEIN), if any: 36-3766069 Mailing Address: 1320 Amble Rd. City: Arden Hills State: MN Zip: 55112 County: Ramsey Name of Chief Executive Officer (CEO): Peter Belsito CEO Daytime Phone: 651-242-3889 CEO Email: peter.g.belsito@gmail.com (permit will be emailed to this email address unless otherwise indicated below) Email permit to (if other than the CEO): NONPROFIT STATUS Type of Nonprofit Organization (check one): = Fraternal = Religious Veterans �✓ Other Nonprofit Organization Attach a copy of one of the following showing proof of nonprofit status: (DO NOT attach a sales tax exempt status or federal employer ID number, as they are not proof of nonprofit status.) ❑ A current calendar year Certificate of Good Standing Don't have a copy? Obtain this certificate from: MN Secretary of State, Business Services Division Secretary of State website, phone numbers: 60 Empire Drive, Suite 100 www.sos._$_t@te.mn.u� St. Paul, MN 55103 651-296-2803, or toll free 1-877-551-6767 IRS income tax exemption (501(c)) letter in your organization's name ❑ Don't have a copy? To obtain a copy of your federal income tax exempt letter, have an organization officer contact the IRS toll free at 1-877-829-5500. ❑✓ IRS - Affiliate of national, statewide, or international parent nonprofit organization (charter) If your organization falls under a parent organization, attach copies of b h of the following: 1. IRS letter showing your parent organization is a nonprofit 501(c) organization with a group ruling; and 2. the charter or letter from your parent organization recognizing your organization as a subordinate. GAMBLING PREMISES INFORMATION Name of premises where the gambling event will be conducted (for raffles, list the site where the drawing will take place): Welsch's Big Ten Supper Club Physical Address (do not use P.O. box): 4703 N Hwy 10. Arden Hills. MN 55112 Check one: City: Arden Hills Zip: 55112 County: Ramsey Township: Zip: County: Date(s) of activity (for raffles, indicate the date of the drawing): June 24. 2023 Check each type of gambling activity that your organization will conduct: Bingo Paddlewheels =Pull -Tabs =Tipboards Raffle Gambling equipment for bingo paper, bingo boards, raffle boards, paddlewheels, pull -tabs, and tipboards must be obtained from a distributor licensed by the Minnesota Gambling Control Board. EXCEPTION: Bingo hard cards and bingo ball selection devices may be borrowed from another organization authorized to conduct bingo. To find a licensed distributor, go to www.mn.gov/gcb and click on Distributors under the List of Licensees tab, or call 651-539-1900.