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<br />Minnesota Lawful Gambling <br /> <br />LG220 Application for Exempt Permit <br /> <br />An exempt permit may be issued to a nonprofit organization 1hat <br />· conducts lawful gambling on five or fewer days, and <br />· awards less than $50,000 in prizes during a calendar year. <br /> <br />Fee is $50 for <br />each event <br /> <br />Page 1 of 2 6/07 <br />For Board Use Only <br />Check # <br /> <br />$ <br /> <br />ORGANIZATION INFORMATION <br /> <br />Organization name Previous gambling permit number <br /> <br />~__~~~ ~_~~ _~_L~ ~ __~u~ ________________ ________~-::--!!-7~-~--_------------ <br />Type of nonprofit organization. Check (~) one. " <br />o Fraternal 0 Religious 0 Veterans IDther nonprofit organization <br />Mailing address I City StatelZip Code County <br />7197 B;uAt-I L:>'~v~ ~..r:-~~,,-~~.J t;~o?,.~ ND~ <br />Name of chief executive officer (CEO) Daytime phone number <br />?~/;,.. ~,~~e-L....ttP~ bl~'-~U- CJ'2-2- <br />ATTACH A COPY OF ONE OF THE FOLLOWING FOR PROOF OF NONPROFIT STATUS <br /> <br />* Do not attach a sales tax exempt status or federal 10 employer numbers as they are not proof of nonprofit status. <br /> <br />_ Non profit 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., 180 State Office Building, St. Paul, MN 55155 Phone: 651-296-2803 <br /> <br />/ <br />1. Internal Revenue Service -IRS income tax exemption [501 (c)] letter in your organization's name. <br />Don' have a copy? To obtain a copy of your federal income tax exempt letter, send your federallD number and <br />the date your organization initially applied for tax exempt status to: <br />IRS, P.O. Box 2508, Room 4010, Cincinnati,OH 45201 <br /> <br />_Internal Revenue Service - Amliate 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 /> <br />a. IRS letter showing your parent organization is a registered nonprofit 501 (c) organization with a group ruling <br />b. the charter or letter from your parent organization recognizing your organization as a subordinate. <br /> <br />_Internal Revenue Service - proof previously submitted to Gambling Control Board <br />If you previously submitted proof of nonprofit status from the Internal Revenue Service, no attachment is required. <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 />L~~...ti-e~\lI~ L-AtL€ lL-c& n~\~b ?o~'Te~r '"i1L-U,~:; .~tH <br /> <br />-. ------------------f---------------------------[------------, ----------] ---- <br />Address (do not use PO box) City Zip Code County <br />...- c:...:st-J~e ~v\~ t.;?p'~6 A,..J t::>~ <br /> <br />...-------------------------------------------------------~------------------------------------------------------------------------------------- ---------------------------------------------- ---------------------------- <br /> <br />Date(s) of activity (for raffles, indicate the date of the drawing) <br />$ArV'~Y' P;C3i2V1t;L'I" cr.rw- 2-t:>t::'~ <br />I <br />Check the box or boxes that indicate the type of gambling activity your organization will conduct <br /> <br />o *Bingo ~ffles 0 *Paddlewheels 0 *Pull-Tabs 0 *Tipboarcls <br /> <br />"~AU-u? ~€ .~'~~-f ,.bT~ <br /> <br />, <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 Ust of Ucensed Distributors, or call 651-639-4076. <br /> <br />~/ <br />