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<br />Minnesota Lawful Gambling <br />LG220 Application for Exempt Permit <br />Fee $50 <br />for each event <br /> <br />An exempt permit may be issued to a nonprofit organization <br />conducting lawful gambling activity on five or fewer days, and <br />awarding less than $50,000 in prizes durings a calendar year. <br /> <br />Page 1 of 2 2/07 <br />For Board Use Only <br />Fee Paid <br /> <br />Check No. <br /> <br />ORGANIZATION INFORMATION <br /> <br />Organization name <br />...- { LfJSJA(~ <br />Type of nonprofit organization. Check ( ) one. <br />I!2rFraternal 0 Religious <br />o Veteran 0 Other nonprofit organization <br />Mailing address /) City <br />I A,e, '/L. iJGV~1 CL-tS- <br />Name of chief executive officer (CEO) <br />First name <br />-rc- $1.-( <br /> <br />PROOF OF NONPROFIT STATUS <br /> <br />Type of proof of nonprofit status. Check (.y) one. Attach a copy (see below) <br /> <br />o Nonprofit Articles of Incorporation or Certificate of Good Standing - Minnesota Secretary of State's Office <br />o Internal Revenue Service <br />~Affiliate of parent nonprofit organization (charter) <br />~ Proof previously submitted and on file with the Gambling Control Board <br /> <br />Sales tax exempt status or federal 10 employer numbers are not proof of income tax exempt status. <br /> <br />Previous lawful gambling exemption number <br /> <br /> <br /> <br />Daytime phone number <br />tb$f-~/E-/ ?t. <br /> <br /> <br /> <br />Minnesota Secretary of State <br />Certificate of Good Standing or <br />Nonprofit Articles of Incorporation <br />Attach a copy of your organization's <br />Certificate of Good Standing (317 A) <br />showing incorporation as a <br />nonprofit organization. <br /> <br />IRS Income Tax Exemption <br />Under a national organization - If your organization falls under a national <br />organization, attach both of the following: <br />1. a copy of the IRS letter showing that your national organization has been <br />a registered nonprofit 501 (c) organization and carries a group ruling, and <br />2. a copy of the charter, or letter from your national organization, recognizing <br />your organization as a subordinate. <br /> <br />This certificate can be obtained <br />from: <br />Minnesota Secretary of State <br />Business Services Division <br />180 State Office Building <br />St. Paul, MN 55155 <br />Phone: 651-296-2803 <br /> <br /> <br />Not under a national organization - If your organization does not fall under a <br />national organization, attach a copy of the IRS income tax exemption <br />[501 (c)] letter in your organization's name. To obtain a copy of your federal <br />income tax exempt letter, send your federallD number and the date your <br />organization initially applied for tax exempt status to: <br />IRS <br />P.O. Box 2508 <br />Room 4010 <br />Cincinnati, OH 45201 <br /> <br />GAMBLING PREMISES INFORMATION <br /> <br />Name of premises where gambling activity, will be conducted (for raffles, list the site where the drawing will take place) <br />U t5 0, f'A-tAL <br /> <br />Address (do not use PO box) ^.. City Zip Code. County <br />lJI7C l#-' Ccf,"T(!!ILv(~ .531J3 <br />Date(s) of activity (for raffles, indicate the date of YJ1 drawing) <br />4 - ZeXj <br /> <br />Check the box or boxes that indicate the type of gambling activity your organization will be conducting: <br /> <br />o *Bingo ~affles D *Paddlewheels D 'Pull-Tabs 0 *Tipboards <br /> <br />*Gambling equipment for pull-tabs, tipboards, paddlewheels, and bingo (bingo paper, <br />hard cards, and bingo number selection device) must be obtained from a distributor <br />licensed by the Gambling Control Board. To find a licensed distributor, go to <br />www.gcb.state.mn.us and click on List of Licensed Distributors. Or call 651-639-4000. <br /> <br /> <br /> <br />/d <br />