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iT11� 1�'��ila�i.fl�ifiC�_� ►�1:- ��- - <br />LG220 Application for Exempt Permit <br />An exempt permit may be issued ta a nonprofit organization that: <br />- canducts lawfu[ gambling on five ar fewer days, and <br />- awards less than $50,000 in prizes during a calendar year. <br />if tota! prize value for the year will be $1,500 or less, contact the (icensing <br />specialist assigned to your county. <br />OI�GANIZATIQN INFORMATION <br />Organization name <br />Minnesota tax ID number, if any Federal <br />7ype of nonprofit arganization. Check one. <br />Fraternal Religiaus <br />Mailing address <br />Name of chief e�,etutiv,e o�cer [C�O] <br />NC�NPRtJFiT STATUS <br />� <br />r/13 Rage i af 2 <br />Application fee �non refunaabie� <br />If application is Qostmarked or received 30 days ar <br />mare before the e�ent $50; otherwise $100. <br />Previous <br />�� t��2 ,� <br />ID number (FEIN), if any <br />�ambling permit number <br />�' �� l � �% �'/ S' �G�t? <br />Veterar�5 �Other nanprofit arganfzation <br />City � State Zip code Co�j'�ty <br />•�/%9 /ipS.E'ri�.cc� dJ�/f/ ,._ .� ��/.:� KAmS� <br />[7aytime phone number E-mail address <br />� �G� - '�'i'% ' �.�fS�P ���a/1n Con .5�3fJ <br />A#tach a copy of ONE af the fallowing far proof of nonprofit status. <br />Nonprafit Articles of Incorparation iiR a current Certificate of Goad Stand�ng. <br />Don't have a copy? This certifi�ate m�st be obtained each year from: <br />Secretary of State, Buslness Services Div., 50 Empire Drive, Suite 10Q, St. Paul, MN 55103 <br />Phone: fi51-296-2803 <br />�� <br />_ IRS income tax exsmption [S�1(c}] letter in yaur argan�zation's name. <br />Don't have a capy? Ta abtain a copy af your federal income tax exernpt 4etter, have an organization officer contact <br />�be iRS at 877-829-550U. <br />��_ <br />T IR5 - Affiliate af national. statewide, ar international parent nonprofit organiza#ion [charter] <br />If your organizatian falfs under a pare�t organization, attach copies of both of the following: <br />a. IRS letter showing your parent organization is a nanproflt 5Q1(c) organization with a group r�fing, and <br />b. the charter or letter from your parent organization recognizing your arganizaCion as a subardinate. <br />GAMBLING PREMISES INFQRMATION <br />of premises where the g <br />Address [do not use PO box] <br />E?ate[s] of acrivity. For rafFl <br />event will be canducted. For rai'f[es, list the site where the drawing will take place. <br />UILC E' <br />City or <br />indicate the date of the drawing. <br />ic�l4 <br />Cheek each type af gambling activity that your organizaCion wil! conduct. <br />Bingo* __�,_ Rafffe Padcflewheels* Pull-tabs* <br />Zip code �ounty <br />Tipboards* <br />*Gambling equipment for bingo paper, paddlewheels, pull-tabs, and tipbaards must be obtained fram a distributor <br />litensed by the Minnesata Gambling Cantrol Board. EXCEPTION: Bingo hard cards and binga number selection devices <br />may be borrowed from another organization authorized to concfvct Dinga. <br />To �nd a[icensed distributor, go to www.gcb.state.ra».t�s and click on Distributors <br />under the WHO'S WHQ� LIST OF LICENSEES, or call 651-539-1900. <br />