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Mar 26 1010:23a Jean and Ed Kern Minnesota Lawful Gambling LG220 Application for Exempt Permit An exempt permit may be issued to a nonprofit organization that: - conducts lawful gambling on five or fewer days, and - awards less than $50,000 in prizes during a calendar year_ ORGANIZATION INFORMATION 651 - 489 -6050 p.2 Page 1 of 2 9108 Fee is $50 for each event For Board Use Only Check # $ Organization name previous gambling permit number S � 9 C-v1e- Vi e a e- v'.s C c i IC— CCkLLrC - t2.� X s o o$ Type of nonprofit organization. Check one. Fraternal ®Religious D Veterans Other nonprofit organization Mailing address City State Zip Code County '708 7 RoaA, LA - t eY'u; 11e R7A/ � 038 us2Q Name of chief executive officer (CEO) Daytime phone number Email address F►+Z r^a_IzL "i _ L4 �9- 743 '7 :S+gr.v -SZ us��i)), Aet Attach a copy of ONE of the following for proof of nonprofit status.theck one. Do not attach a sales tax exempt status or federal ID employer numbers as they are not proof of nonprofit status. Nonprofit Articles of Incorporation OR a current Certificate of Good Standing. Don't have a copy? This certificate must be obtained each year from: Secretary of State, Business Services Div., 180 State Office Building, St. Paul, MN 55155 Phone: 651 -296 -2803 Cl ] IRS income tax exemption [501(c)] letter in your organization's name. Don't have a copy? To obtain a copy of your federal income tax exempt letter, have an organization officer cordactthe IRS at 877 - 829 -5500. !�f IRS - Affiliate of national, statewide, or international parent nonprofit organization (charter) If your organization falls under a parent organization, attach copies of both of the following: a. IRS fetter showing your parent organization is a nonprofit 501(c) organization with a group ruling, and b. the charter or letter from your parent organization recognizing your organization as a subordinate. IRS - proof previously submitted to Gambling Control Board If you previously submitted proof of nonprofit status from the IRS, no attachment is required. GAMBLING PREMISES INFORMATION Name of premises where gambling activity will be conducted (for raffles, list the site where the drawing wiil take place) ca+• OEi/i�V T 6_i'ts�1- O it1'rYtbl Address (do not use PO box) City Zip Code County 1 Cen ^v: 1/e koad L vile �So38 05A Dale(s) of activity (for raffles, indicate the date of the drawing) to a t)�ri A 511..E Lj > ad 1 O Check the box or boxes that indicate the aatity your organization will conduct: ❑ Bingo` ® Raffles 0 Paddlewheels` n Pull -Tabs' E] Tipboards' * Gambling equipment for pull -tabs, bingo paper, tipboards, and paddlewheels must be obtained from a distribubor licensed by the Also complete Page 2 of this form. Gambling Control Hoard. EXCEPTION: Bingo hard cards and bingo number selection devices may be borrowed from another organization authorized bo conduct bingo. Print Form To find a licensed distributor, go t:o www.gcb.stabe.mn.us and click on list Reset Form of Licensed Distributors, or call 651 - 639.9076. 51