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Orgianiu z,ati�on name St.1 Rooe of Lima Catholic Church Type ofnionprofit organization. Check one., 1:1 (Fraternal Ej Religious [:]Veterans Attachment A MIMI _It Irllll days more then 30 days befbre the event before the event $100 $50 Previous gambling permit number X-62002 E] Other nonprofit, organization 10 4t 0 -il Mne,hi n-Mt Do not attach a sales tax exem pt staitus or federal ID employer numbers as they are not proof of nonprofit status. Nonprofit ArUclies of Incorporation OR a current Certificate of Good Standing. Don1 have a copy? This certificate must, be olbtaiined year from: Secretary of State, Business Services Div, 180 State Office Building,, St. Paul, MN 55156 Phone.- 651-296-2803 IRS Income tax exemption 1601(()], letter In your organization's name. Dion"t have a copy? To obtain a copy, of your federal income tax exempt letter, have an organi;zation offi cer contact, the (IRS, at 87'7-82,19-5500. IRS - Affiliate of national, statewide, or intarnational parent nonprofit organization (charter) I If your organ�izationi, falls, under a parent" organization, attach copies of both of the following: a. IRS letter 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 organizaflon as a subordinate. DT-3 JJ IN�ame of piremises where gamibling activity will be, conducted (fair raffles, list the site where the drawling will take place) St,. Rose of L P,&rkln Lot Address (do, not use PO box) City Zip Code County 20712 Hamilne Ave. N., Roseville 515113 Ramey Date(s) of activity i raffies, Indicate the date of the drawing) September 17, 2011, he the box or biaixes, that indicate the t)" of giambling activity your organization willl conduct: Z Bingo* D&Raffles, Paddlewheels* Dqpull-Tabs* MTipboards* * Gambling equipmen�t for plull-tabs, bingo, paper, tipboards, and - Also complete paddlewheels must be obtained from a distributor licensed by the Page 2 of this form. Gambling Control Board. EXCEM ON: Bingo hard cards and bingo, number selecUon devices may be borrowed from another organization authoHHed to conduct Ungo.1 rya To finid a licensed distributor, go to www.gcb.state.mmus and dli k, on List of Licen�sed Dilstributors,,, or call 39-4000l.