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LG220 Application for Exempt Permit Pa e 28of 2 9 Local Unit of Government Acknowledgment CITY APPROVAL COUNTY APPROVAL for a gambling premises for a gambling premises located within city limits located in a township The application is acknowledged with no waiting period. he application is acknowledged with no waiting period. The application is acknowledged with a 30-day waiting he application is acknowledged with a 30-day waiting period, and allows the Board to issue a permit after 30 days period, and allows the Board to issue a permit after (60 days for a ist class city). 30 days. �The application is denied. he application is denied. Print City Name: Print County Name: Signature of City Personnel: Signature of County Personnel: Title: Date: Title: Date: TOWNSHIP (if required by the county). On behalf of the township, I acknowledge that the organization is applying for exempted gambling activity within the township limits. (A township has no statutory authority to approve or deny an application, per Minn. Statutes, section 349.166.) Local unit of government must sign. - .. Print Township Name: - Signature of Township Officer: Title: Date: Chief Executi�e Officer's Signatur-e The information provided in this application is complete and accurate to the best of my knowledge. I acknowledge that the financial report will be completed and returned to the B ' in 30 days of the event date. �yChief Executive Officer's Signature: Date:, ��- Print Name: �.�C.b� %a"� . � �'�� Requirements _. : Complete`a separate application for: Financial report and recordkeeping required. ` • all gambting:cond_ucted on two:or. more. co.nsecutive:days; or A financial report form and instructions will be sent with your • all gamtiling conducted on one day. permit, or use the online fill-in form available at _ Only one applicetion is required if one or more raffle drawings are www.mn.gov/gcb. conducted on the same day. Within 30 days of the event date, complete and return the Send application with: -. financial reportform to the Gambling Control Board. Your a copy of your proof of nonprofit status, and organization must keep all exempt raffle records and reports for �/ application fee (nonrefundable). If the application is 3-1/2 years (Minn. Statutes, section 349.166, subd. 2(�). postmarked or received 30 days or more before the event, the application fee is $50; otherwise the fee is $100. Make Questions? check payable to State of Minnesota. Call the Licensing Section of the Gambling Control Board at 651-539-1900. To: Gambling Control Board This form will be made available in alternative format (i.e. large , 1711 West County Road B, Suite 300 South print, Braille) upon request. Roseville, MN 55113 Data privacy notice: The information requested on tFiis form (and any attachments) will be used by the Gambling Control Board (Board) to determine your organization's qualificatio�s to be lnvolved in lawful gambling activities in Minnesota. Your organization has the right to refuse to supply the information; however, if your organization refuses to supply this information, the Board may not be able to determine your organization's qualifications and, as a consequence, may refuse to issue a permit. If your organization supplies the information requested, the Board will be able to process the application. Your organization's name and address will be public information when received by the Board. All other information provided will be private data about your organization until the Board issues the permit. When the Board issues the permit, all Information provided will become public. If the Board. do�s not_issue a_permit,_all__ information provided remains private, with the exception of you� organization's name and address which wlll remain public. Private data about your organization are available to Board members, Board staff whose work requires access to the information; Minnesota's Depart- ment of Public Safety; Attorney General; Commissioners of Admiriistration, Minnesota Management & Budget, and Revenue; Legislative Auditor, national and international gambling regulatory agencies; anyone pursuant to court order; other individuals and agencies specifically authorized_b� state_or federal.law to have_access_. to the information; individuals and agencies for which law or legal order authorizes a new use or sharing of information after this notice was given; and anyone with your written consent.