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<br />Minnesota Lawful Gambling <br /> <br />Page 1 of 2 6/08 <br /> <br />LG220 Application for Exempt Permit For Board Use Only <br />An exempt permit may be issued to a nonprofit organization that: Fee is $50 for Check # <br />. conducts lawful gambling on five or fewer days, and <br />. awards less than $50,000 in prizes during a calendar year. each event $ <br />ORGANIZA TION INFORMATION <br />Organization name Previous gambling permit number <br /> ~t. (-:tncxi t v..,l " Cu.t\-1 DI i l- ('" l.lf ch c, ~ DO~ <br />Type of nonprofit organization. Check eJ) one. <br />o Fraternal Q! Religious o Veterans o Other nonprofit organization <br />Mailing address I City StatelZip Code County <br />'1 0 ~ 1 {.-,t\ tton PJ., {' l n~ Ly 'VI \ \.; Nf'J ~)SDO~ Anokc.. <br />Name of chief executive officer (CEO) Daytime phone number <br /> Fe IOCD 1=1 t1C1UcJd (PSl- tfd~-lq31 <br />A TT ACH A COpy dF ONE OF THE FOLLOWING FOR PROOF OF NONPROFIT STATUS <br />* Do not attach a sales tax exempt status or federal ID employer numbers as they are not 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., 180 State Office Building, St. Paul, MN 55155 Phone: 651-296-2803 <br />_ Internal Revenue Service -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 <br /> contact the IRS at 877-829-5500. <br />_Internal Revenue Service - 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 />Xlnternal 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 />GAMBLING PREMISES INFORMATION <br />Name of premises where gambling activity will be conducted (for raffles, list the site where the drawing will take place) <br /> S~. (-ene.'(\c:y.l's Crol-hclll lhw ch . i'tJrofn...lf\,-h \ (f ntH <br />Address (do not use PO box) I City ..J Zip Code I County <br />I , 0 (I (, (.) L t. nt t.\""V\ \ l n.eL C.en1 e.Y'vlllt ~H\J b5D'~'5 AnD )(~ <br />Date(s) of activity (for raffles, indicate the date of the drawing) <br /> t.. "..~l 3 ~OD'8 <br />Check the box 0: boxes that indicate the type of gambling activity your organization will conduct: <br />o *Bingo ~ Raffles 0 *Paddlewheels o *Pull-Tabs o *Tipboards <br /> * Gambling equipment for pull-tabs, bingo paper, tipboards, and paddlewheels must <br /> be obtained from a distributor licensed by the Gambling Control Board. <br /> EXCEPTION: Bingo hard cards and bingo number selection devices may be borrowed <br /> from another organization authorized to conduct bingo. <br /> To find a licensed distributor, go to www.gcb.state.mn.us and click on List of Licensed <br /> Distributors, or call 651-639-4076. <br /> <br /><---Q1 <br /> <br />L____ <br />