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� <br /> Minnesota Lawful Gambling Page � orz ���o <br /> Application fee for each event <br /> LG220 Application for Exempt Permit �ta �ication ostmarkedorreceived: <br /> An exempt permit may be issued to a nonprofit organization that: less than 30 days more than 30 days <br /> - conducts lawful gambling on five or fewer days, and before the event before the event <br /> - awards less than $50,000 in prizes during a calendar year. �100 $50 <br /> ORGANIZATION INFORMATION cn�k # $ <br /> Organization name Previous gambling permit number <br /> �- l� �YL � 1 C-V L i 5 l.-A.l�-+' �G ! 1 G C� l.L_�L� <br /> Type of nonprofit organization. Check one. <br /> � Fratemal � Religious � Veterans � Other nonprofit organization <br /> Mailing address City State Zip Code County <br /> 7 � �oi �or �c�ce� � �eY►f'erUi�l� %�?`� �.-i.�o3� f1�j;� ' <br /> IVame of chief executive officer (CEO) Daytime phone number Email address <br /> �ce..�'h�r �o-rr� �ifz. �v`cz.lc� �.5"i- `��9-7�3� 5�' evtsr us-�rv�il ,ne:.f <br /> Attach a copy of ONE of t following for proof of nonprofit status. Ch k one. <br /> Do not attach a sales tax exempt status or federal ID employer numbers as they are not pr�f of nonprofit status. <br /> ❑ Nonprofit Articles of Incorporation OR a current Certificate of Good Standing. <br /> Don't have a copy? This certificate must be obtained each year from: <br /> Secretary of State, Business Services Div., 180 State Office Buildi�g, St. Paul, MN 55155 Phone: 651-296-2803 , <br /> � IRS income tax exemption [501(c)] letter in you� organization's name. <br /> Don't have a copy? To obtain a copy of your federal income tax exempt letter, have an organization officer � <br /> contact the IRS at 877-829-5500. j <br /> � IRS - AfRliate of nationat, statewide, or internation I parent nonprofit organization (charter) I <br /> If your organization falls under a parent organization, attach copies of both of the following: I <br /> a. IRS letter showing your parent organization is a nonprofd 501(c) organization with a group ruling, and <br /> b. the charter or letter from your parent organization recognizing your organization as a subordinate. <br /> d IRS - proof previously submitted to Gambling CoMrol Board I, <br /> If you previously submitted proof of nonprofit status from the IRS, no attachment is required. I� <br /> GAMBLING PREMISES INFORMATION I <br /> Name of premises where gambling activity will be conducted (for raifles, list the site where the drawing will take place) ', <br /> c3� •(� �ir1��1 i� V��S 'T �r iS �l � m wl t� f'� �.e.v� t� <br /> Address (do not use PO box) City Zip Code Counry <br /> �� � 9� ► ' 1� lZo '11 �'�D;"sff U5.9 - <br /> �� � r�v ; e cz c� �r ✓r � � <br /> Date(s) of activity (for raifles, indicate the date of the drawing) <br /> Su� d� , � �"-I� , ao I � <br /> hedc the box or boxes t indicate the type of gambting activity your organization will conduct: <br /> � Bingo' � Raifles � Paddlewheels* � Pull-Tabs" ❑ Tipboards" <br /> * �amWing equipment for pull-tabs, bingo paper, tipboards, and <br /> paddlevdheels must be obtained t�om a distributor licensed by the Also complete <br /> Gambling Control Board. IXCEPTION: Bingo hard cards and bingo Page 2 of this form. <br /> number selection devices may be borrowed from another organization <br /> authorized to conduct bingo. Print Form <br /> To find a licensed distributor, go to www.gcb.state.mn.us and didc on List <br /> of Ucensed Distributors, or catl 651-639-4000. Reset Form <br /> 7 <br />