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MINNESOTA LAWFUL GAMBLING 3/14 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 -awards less than$50,000 in prizes during a calendar year. If application is postmarked or received 30 days or If total prize value for the year will be$1,500 or less,contact the licensing more before the event$50; otherwise$100. specialist assigned to your county. ORGANIZATION INFORMATION Organization name Previous gambling permit number Centerville Lions Club Minnesota tax ID number,if any Federal employer ID number(FEIN), if any NA 23-7391509 Type of nonprofit organization. Check one. Fraternal Religious Veterans X Other nonprofit organization Mailing address City State Zip code County 7155 Brian Drive Centerville MN 55038 Anoka Name of chief executive officer[CEO] Daytime phone number E-mail address Greg IGeselhorst 612-221-9122 gkieseforst@q.com 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 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 orgpnization officer contact the IRS at 877-829-5500. X 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. Kelly's Komer Address [do not use PO box] City or township Zip code County 7098 Centerville Road Centerville 55038 Anoka Date[s] of activity. For raffles, indicate the date of the drawing. May 31, 2014 Check each type of gambling activity that your organization will conduct _Bingo*X Raffle[total value of raffle prizes awarded for year S5'000'90—Paddlewheels* _Pull-tabs* Tpboards* *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.9eb-state.ma.us and dick on Distributors under the WHO'S WHO?LIST OF LICENSEES,or call 651-539-1900.