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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 Ness than$50,000 In prizes during a calendar year. If application is postmarked or received 30 days or <br /> ff 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 5503+8 Anoka <br /> Name of chief executive officer[CEO] Daytime phone number E-mail address <br /> Nancy Johnson 651-247-7444 Nanky_Johnson@gsl.com <br /> NONPROFIT ST'A'TUS <br /> Attach a copy of ONE of the following for proof of nonprofit status. <br /> Nonprofit Artices 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 /> Nana of premises where the gambling event will be conducted. For raffles,list the site where the drawing will take place. <br /> Centerville Lake;Centerville Lion Prize Area <br /> Address[do not use PO box] Qty or township Zip code County <br /> 7281 Hwy 14 Centerville 66038 Anoka <br /> Dates]of activity. For raffles,indicate the date of the drawing. <br /> Same Day Raffle on Saturday February 20th 2016 <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.inn.us and dick on Distributors <br /> under the WHO'S WHO?LIST OF LICENSEES,or call 651-539-1900. <br /> 98 <br />