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MINNESOTA LAWFUL GAMBLING 1/13 Page 1 of 2 <br /> LG220 Application for Exempt Permit <br /> An exempt permit may be issued to a nonprofit organization that: Application fee (non refundable) <br /> -conducts lawful gambling on five or fewer days, and <br /> -awards less than $50,000 in prizes during a calendar year. If application is postmarked or received 30 days or <br /> If total prize value for the year will be$1,500 or less,contact the licensing more before the event$50; otherwise$100. <br /> specialist assigned to your county. <br /> ORGANIZATION INFORMATION <br /> Organization name Previous gambling permit number <br /> Centerville Lions Club X-04725 <br /> Minnesota tax ID number, if any Federal employer ID number(FEIN), if any <br /> 23-7391509 <br /> Type of nonprofit organization. Check one. <br /> Fraternal Religious Veterans X Other nonprofit organization <br /> Mailing address City State Zip code County <br /> 7155 Brian Drive Centerville MN 55038 Anoka <br /> Name of chief executive officer [CEO] Daytime phone number E-mail address <br /> John Thill 651-653-4641 jtbandit@comcast.net <br /> NONPROFIT STATUS <br /> Attach a copy of ONE of the following for proof 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., 60 Empire Drive, Suite 100, St. Paul, MN 55103 <br /> Phone: 651-296-2803 <br /> X IRS income tax exemption [501(c)] letter in your organization's name. <br /> Don't have a copy? To obtain a copy of your federal income tax exempt letter, have an organization officer contact <br /> the IRS at 877-829-5500. <br /> IRS-Affiliate of national, statewide, or international parent nonprofit organization [charter] <br /> If your organization falls under a parent organization, attach copies of both of the following: <br /> a. IRS letter showing your parent organization is a nonprofit 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 /> GAMBLING PREMISES INFORMATION <br /> Name of premises where the gambling event will be conducted. For raffles, list the site where the drawing will take place. <br /> St. Genevieve Parish Community Center <br /> Address [do not use PO box] City or township Zip code County <br /> 6995 Centerville Road Centerville 55038 Anoka <br /> Date[s] of activity. For raffles, indicate the date of the drawing. <br /> Saturday April 18th 2015 <br /> Check each type of gambling activity that your organization will conduct. <br /> Bingo* X Raffle Paddlewheels* Pull-tabs* Tipboards* <br /> *Gambling equipment for bingo paper, paddlewheels, pull-tabs, and tipboards must be obtained from a distributor <br /> licensed by the Minnesota Gambling Control Board. EXCEPTION: Bingo hard cards and bingo number selection devices <br /> may be borrowed from another organization authorized to conduct bingo. <br /> To find a licensed distributor, go to www.gcb.state.mn.us and click on Distributors <br /> under the WHO'S WHO?LIST OF LICENSEES, or call 651-539-1900. <br /> 43 <br />