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MINNESOTA LAWFUL GAMBLING 8/14 Page 1 of 2 LG220 Application for Exempt Permit An exempt permit may be issued to a nonprofit organization that: App�ICdtlOtl f@e (nonrefundable) • conducts lawful gambling on five or fewer days, and if the application is postmarked or received • awards less than $50,000 in prizes during a calendar year. 30 days or more before the event, the application If total prize value for the year will be $1,500 or less, contact the Licensing fee is $50; otherwise the fee is $100. Specialist assigned to your county. Organization Information Org nization Name: Previous Gambling Permit Number. � i�S i e_. ��a �ti� �t � C'_ l�f� l� Minnesota Tax ID Number, if any: Federal Employer ID Number (FEIN), if any: �� Type of Nonprofit Organization (check one): � Fraternal � Religious � Veterans ' Other Nonprofit Organization Mailing Address: City: State and Zip: County: ' � � i�i U.2 �w c� c� � i�. � 6V � �2-i�-1�` �'! rV �5 L-f 3 � Name of Chief Exe tive Officer (CEO): Daytime Phone: Email: l � � rZ�S � � � -� � - �CI � � �a.�a.r�� G��rv�C�`1��,,c. Nonprofit Status - Attach e 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: Minnesota Secretary of State _ Business Services Division ' _ ... . _ 60 Em.pire Drive, Suite 100 - St: Paul, MN 55103 _, `: Phone: 651-296-2803 �IRS income tax exemption (501(c)) letter in your orgenization'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. an 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 plaae):: . � t7 � @ � f ►� � at � � �' � fZ lJ� ►�v� - � � Address (do not use PO box): City or Township; Zip Code: County; , - ��I �►�� ►�,� �� nse�� 1� 5� � 3 _ se. Date(s) of activity (for raffles,_indi e the date of the drawing): ��►'�-�-- ,� � � � t � Check each type of gambling activity that your organization will conduct: Bingo* �Paddlewheels* �Pu11-Tabs* �Ti boar S* �. ,� ��.'� � �,-�- n � � � Raffle (total value of raffle prizes awarded for the year: $�� C� ) *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.mn.gov/gcb and click on Distributors under the LIST OF LICENSEES, or call 651-539-1900.