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Minnesota Lawf'ul Gambling <br />LG220 Application �or Exempt Pe�mit <br />Attachment A <br />Page 1 of 2 9108 <br />Fee is $50 for each e�ent <br />An exempt permit may be issued to a nonprofif orgar�ization that: For Board Use Oniy <br />- conducts lawful gambling on five or fewer days, and <br />- awards less than $50,OD0 in prizes during a calendar year. Check # $ <br />�RGANIZATION INFORMATION <br />Organization name Previous gambling perrr�it number <br />St. Rose of �ima Catholic Church <br />Type of nonprofit organization. Check one. . <br />� Fraternal ❑X Religious � Veterans � Qther nonprofit organization <br />Mailing address City Staie Zip Code County <br />2048 Namline Ave. t� Roseville MN 55113 Ramsey <br />Name of ahi�f executi�e officer {CEO) Daytime phone num6er Email address <br />p;1�.�� ... . '_r_.��..n ' ---- <br />Attach a copy of ONE of the following for proof of nonprofit status. Check one. <br />Do not attach a sales tax exempt status ar federal iD empioyer numbers as they are not proof af nonprofit status. <br />�Nonprofit Articles of Incorporation OR a current Certificate of Good Standi�g. <br />Dort't have a copy? This certificafe must be obtair�ed each year from: <br />Secretary of State, Business Services �iv., 1$0 State Office Building, St. Paul, MiV 55155 Phone: 651-296-2803 <br />� IRS income tax exemption [501(cj] letter in your organization's name.. <br />Dan't have a copy? io obtain a copy of your federal income tax exer�pt letter, �rave an organization officer <br />contact the IRS at $77-$29-5500. <br />� fi2S - Affili.ate of natior�al, statewide, or internatianat parent nonprofit organization (charter) <br />If you� organization falls under a parent organization, attach copfes of bo#h of the foilowing: <br />a. IRS letter showing your parerit organization is a nonprofit 501(c) organizatian with a group ruling, and <br />b. the charter or letter from your parent organization recognizing your organization as a subordinate. <br />� IRS - proof previously submitted to Gambling Control Board <br />If yau previously submitted proof af nonprofit status from fhe fRS, no attachment is required. <br />GAMB�fNG PREMISES INFORMATION <br />Narne o€ premises where gambling activity will be conducted (far rafffes, list the site where the drawing will take �lace) <br />St. Rose of �ima parking lot <br />Address (do not use PQ box) City Zip Code Caunty <br />2fl72 Hamline A�e. N. Rose�ille 55113 Ramsey <br />�ate(s} of activity {for rafFles, indicate the date of the drawing) <br />919 912009 to 911 912 0 0 9 <br />heck the box ar boxes that indicate the type o€ gambling activity your organization will conduct: <br />� Bingo` � Raffles �: Paddlewheels` ❑ Pu�l-Tabs" ❑ iipboards' <br />* Garnbling equipment for puli-tabs, bingo paper, tipboards, and <br />paddlewheels must be obtained from a distridutor iicensed �y the Also complete <br />Gambling Control Board. EXCEPTION: 8ingo h�rd cards and bingo Page 2 of this form. <br />nurnber selection devices may be borrowed from another arganization <br />authorized to conduct bingo. FifE-in & Print Form <br />To find a licensed distributor, go ta www.gcbstate.mn.us and click on List Reset Form <br />of l.icensed Distributors, or call 651-639-4076. <br />