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MINNESOTA GAMBLING CONTROL BOARD ChecKUst for Exemnt Hattie 4/22 Page 3 of 4 Organization Name: Previous Gambling Permit 0: Date of Raffle Drawing: Ducks Unlimited North Suburban Chapter X- 03315-23-019 June 10, 2023 INSTRUCTIONS: • The purpose of this form is to help your organization conduct exempt raffles in compliance with the requirements listed below. Detailed information regarding each requirement is available by clicking on the following links [in blue italics): 1) applicable statutes and rules; 2) the Lawful Gambling Manual chapter on raffles; 3) the online class, "Conduct of Raffles"; and 4) the phone number and email address of your county's Compliance Specialist. • After reading each checklist item, mark "Yes" to indicate that you understand the requirement and agree to comply. After answering "Yes" to each applicable item, your organization's CEO must sign the acknowledgment below. Include the completed checklist as part of your application to conduct an exempt raffle. • If tickets will be sold prior to the event, mark "Yes" to item #1 and mark "N/A" to items #2 and #3. • If tickets are sold only at the event using theater tickets, mark "N/A" to item #1 and Yes N/A answer "Yes" to items #2 and #3. a 1. Tickets are printed in accordance with MN Rule 7861.0310. I 11:1 2. Tickets contain the sequential number of the raffle ticket. (349.173) 3. A list of prizes and a statement of other ❑ El relevant information is made available to ticket purchasers. (349.173) Yes Prizes a 4. The organization is the sole owner of all the real or personal property to be awarded. (7861.0260) 5. A merchandise certificate is used when a prize requiring registration or licensure (guns, cars, ATVs, etc.) is offered. (7861.0260) 6. Prizes must not consist of lawful gambling equipment including raffle tickets for another raffle. (7861.0260) 7. The total value of lawful gambling prizes awarded (use fair market value for donated prizes) does not exceed 550.000 in a calendar vear. (349.1661 8. Alcohol is only awarded as a prize to persons who ademonstrate that they are 21 years of age or older (340A.707) Yes I Conduct 9. Only cash, personal checks, cashier's checks, money orders, travelers' check, and debit cards may be accepted (NO CREDIT CARDS). (349.2127) (7861.0260) ' 10. The method of selection cannot be manipulated or v- based on the outcome of an event not under the organization's control. (349.173) 11. Persons are not required to be present at a raffle adrawing to be eligible to win. (349.173) (7861.0310) RIJ 12. Raffle tickets are not sold to or won by persons underage 18. (349.181) (7861.0310) 13. Purchasers are not required to buy anything other than the ticket. (349.173) (7861.0310) Yes House Rules 14. Clear and legible house rules in accordance with MN Rule 7861.0310 are prominently posted at the point of winner selection. Yes Post Raffle Conduct 15. An exempt permit financial report (LG220A) must be submitted to the Gambling Control Board within 30 days of the gambling occasion. (349.166 16. Gambling funds may only be spent for allowable expenses and lawful purposes. (349.12 3a & 25) a 17. Gambling records must be kept for 3'% years. (7861.0310) CHIEF EXECUTIVE OFFICER'S SIGNATURE (required) Noncompliant Activity: I acknowledge by signing below that my organization must follow all raffle rules and that any gambling activity conducted by the organization at the event that is not in compliance with Minnesota Statute and Rule may subject the organization to citation or the inability to receive future permits to conduct gambling. I understand that my permit will not be issued until this form has been completed and submitted to the Minnesota Gambling Control Board. Sign atu Dat Print Name: I z� ��L( (7-3 Peter Belsito Data privacy notice: The information requested on this form (and any attachments) will be used by the Gambling Control Board (Board) to determine your organization's qualifications to be involved in lawful gambling activities in Minnesota. Your organization has the right to refuse to supply the information; however, if your organization refuses to supply this information, the Board may not be able to determine your organization's qualifications and, as a consequence, may refuse to issue a permit. If your organization supplies the information requested, the Board Your organization's name and address will be public information when received by the Board. All other information provided will be private data about your organization until the Board issues the permit. When the Board issues the permit, all information provided will become public. If the Board does not issue a permit, all information provided remains private, with the exception of your organization's name and address which will remain public. Private data about your organization are available to Board members, Board staff whose work requires access Safety: Attorney General; Commissioners of Administration, Minnesota Management & Budget, and Revenue; Legislative Auditor, national and international gambling regulatory agencies; anyone pursuant to court order; other individuals and agencies specifically authorized by state or federal law to have access to the information; individuals and agencies for which law or legal order authorizes a new use or sharing of information after this notice was given; and anyone with your written consent. This form will be made available in alternative format (i.e., large print, braille) upon request. An equal opportunity employer