2013-01-09 CC Packet - Laserfiche WebLink

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MINNESOTA LAWFUL GAMBLING 12/12 Page 1 of 2 LG220 Application for Exempt Permit An exempt permit may be issued to a nonprofit organization that: Application fee (non refundable) - conducts lawful gambling on five or fewer days, and If application posted or received: - awards less than $50,000 in prizes during a calendar year. less than 30 days more than 30 days If total prize value for the year will be $1,500 or less, contact before the event before the event the licensing specialist assigned to your county. $100 $50 ORGANIZATION INFORMATION Organization name Previous gambling permit number Centerville Lions Club X -04725 Minnesota tax ID number, if any Federal employer ID number (FEIN), if any 23- 7391509 Type of nonprofit organization. Check one. Fraternal Religious Veterans X Other nonprofit organization Mailing address City State Zip ode County 7155 Brian Drive Centerville MN 55 Anoka Name of chief executive officer [CEO] Daytime hone number E -mail address John Thill 9 1 51-6 3-4641 jtbandit @comcast.net NONPROFIT STATUS Attach a copy of ONE of the following for proof of nonprofit status. Nonprofit Articles of Incorporation OR a current Certificate of Good Standing. Don't have a copy? This certificate must be obtained each year from: Secretary of State, Business Services Div., 60 Empire Drive, Suite 100, St. Paul, MN 55103 Phone: 651 -296 -2803 X IRS income tax exemption [S01(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 at 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 both of the following: a. IRS letter showing your parent organization is a nonprofit 501(c) organization with a group ruling, and b. 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. Centeville Lake; Centerville Lion Prize Area Address [do not use PO box] City or township Zip code County 7281 Hwy 14 Centerville 55038 Anoka Dates] of activity. For raffles, indicate the date of the drawing. Same Day Raffle on Saturday February 16th 2013 Check each type of gambling activity that your organization will conduct. Bingo* X Raffle Paddlewheels* Pull-tabs* Tipboards* *Gambling equipment for bingo paper, paddlewheels, pull -tabs, and tipboards must be obtained from a distributor licensed by the Minnesota Gambling Control Board. EXCEPTION: Bingo hard cards and bingo number selection devices may be borrowed from another organization authorized to conduct bingo. To find a licensed distributor, go to www.gcb.state.mn.us and click on Distributors under the WHO'S WHO? LIST OF LICENSEES, or call 651 - 639 -4000. 31