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MINNESOTA LAWFUL GAMBLING 3/14 Page 1 of 2 LG220 Application for Exempt Permit An exempt permit may be issued to a nonprofit organization that: �Qpp�ICat1011 feG' (non refundable) - conducts lawful gambling on five or fewer days, and - awards less than $50,000 in prizes during a calendar year. If application is postmarked or received 30 days or If total prize value for the year will be $1,500 or less, contact the licensing more before the event $50; otherwise $100. specialist assigned to your county. ORGANIZATION INFORMATION Organization name Previous gambling permit number Saint Rose of Lima Church X- 62002 Minnesota tax ID number, if any Federal employer ID number (FEIN), if any 8570281 41-0790158 Type of nonprofit organization. Check one. Fraternal X Religious Veterans Other nonprofit organization Mailing address City State Zip code County 2048 Hamline Avenue N Roseville MN 55113 Ramsey Name of chief executive officer [CEO] Daytime phone number E-mail address Fr. Robert Fitzpatrick 651-645-9389 frfitz@saintroseoflima.net NONPROFIT STATUS Attach a copy of ONE of the following for 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., 60 Empire Drive, Suite 100, St. Paul, MN 55103 Phone: 651-Z96-2803 X IRS income tax exemption [501(c)] (etter 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 contact the IRS at 877-829-5500. 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 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 organization as a subordinate. GAMBLING PREMISES INFORMATION Name of premises where the gambling event will be conducted. For raffles, list the site where the drawing will take place. Saint Rose of Lima Church Parking Lot Address [do not use PO box] City or township Zip code County 2048 Hamline Avenue N Roseville 55113 Ramsey Date[s] of activity. For raffles, indicate the date of the drawing. July 26, 2014 Check each type of gambling activity that your organization will conduct. BingO* X Raffle [total value of raffle prizes awarded for year $ ]_Pdddlewheels* _Pull-tabs* _Tlpboard5* *Gambling equipment for bingo paper, paddlewheels, pull-tabs, and tipboards must be obtained from a distributor licensed by the Minnesota Gambling Control Board. EXCEPTION: Bingo hard cards and bingo number selection devices may be borrowed from another organization authorized to conduct bingo. To find a licensed distributor, go to www.gcb.state.mn.us and click on Distributors under the WHO'S WHO? LIST OF LICENSEES, or call 651-539-1900.