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Attachment A <br />Mlnnesnta �a�rfu! Gambfing Pege 9 of 2 e�� <br />LG22t3 A lication for Exempf Permif <br />For Board Use pnly <br />An exempt pertnit may be issued tn a nanprofrt organizafion that: FE,se iS �'rJQ fQP CheckN <br />• condusts lavvful gembling on five or ie�uer days, and <br />• a+Kards �ess than �50 oc3o �n pnzes dunng a calendar year. eaGFl E'VLi"1� � <br />E� � ' - <br />.. . . ... - {�}ya '� a ] t ' f �'� ' ' ^� � S 2, <br />y - . , �- . .�s _ <br />�E,� } � <br />r _ . � . n �Til.'i -. f, 'Ril��i �-'��, r. }S ' . . . C. <br />. t.. #e. . . �„ �. � ,..�Jr. z � . � . _: �. ,� � ! '. ��. � �/ : <br />Organization name . -., ..... . , .- .....` . <br />�ube�ous �e���is �I� ti�C�.. Previous aam��inn nRrmi�.number <br />� •� <br />Type of no�prof�i organization, Check {) one. <br />❑ Fratsrnai ❑ Retigious ❑ Veterans [�Otf�er non�rofit organization ! <br />Mafling aqUr�,ss , .. � � ^,_. <br />� <br />Name of chief e�c�tive oiiicer (CEQ) <br />V_ � ._ � � � - - <br />�� <br />� <br />f "'" r <br />C}a+�ime ohone� numbe,r <br />�_.._... <br />0 <br />'* Do nat attarh a saiES tax exempt siat�s ar €edereE IL1 ernployer numbers as tfiey are noE prooF of nnnproft s�tus, <br />` Nonprotft ArtfcEes of tnearporation OR a currenE Certitica9e oi Gaod 5tanding. <br />bQn'i have a capy? ihis cettiticaie must be obtained eaph yeer frprn: <br />Secretary of State, Business Services biv., 180 State pfflCe Bullding, St. paul, MN 55155 Phona; 65i-296-2803 <br />; <br />_'�ntemai Re�enue Service - IRS income tax exemption [5ot (c}) Istter irt your ptganizstton's narrte, <br />- Don't have a copyT To obtaln a copy nf your federa! income tax exempi letter, send your fetleral ID nurnqer a�d <br />ihe rtate yaur orgai�ization InitialEy epplied for tax exempt stetus to; <br />lAS, P.O. Bpx 2508, Rpom 4610, Clncinnati, flH 452U1 <br />�ernal Revenue Servlc� - Aitfliate of naUonai, slstewfde, or interttatiortal parent nonproTit argahfzaiinn (charter} <br />If your organizafian falEs under a parent organiza�ion; attach copies of �I ot the following; <br />a. IRS letter showing y4ur parent organlradan is a regisiered nonprof�t 507 (c) organiration witti a group ruling <br />b. ihe charier or letter �'orn your parent organization recc�niZir,g ya�r organizatiqn as a subordinate. <br />Enternaf R�vanue 5etvfce - proof previoLSly sui��trftterf to Gambling Controf Boarrf <br />#f yau prevfously su6mitted proaf of nanprofii status irom the Iniema� F�evenue 5ervice, r�o attachmen! is req�sired,. <br />Ha►'te of premises where gambling activiEy will ba cand�cted (for raffles, list F3ie site where th� y�`" �, ��`�I��. ..�y Jj� �` � <br />�� � �� e dravv3R wi0 take pl.aCej <br />Address {do�ot� p0 box) City �p Cade Caun <br />Ct�.��.r�,E�� A 1�1 ��e�,; � S� ty <br />Oate(s} ai a�tivlty (fo'rafFles, indicaie the date of the drawing) <br />Check the box o�ox that fndicate the type of gambling aeetivity your organization wlli conduct: <br />❑ •8ingo Fiaffies ❑ "Paddlewheels ❑ *pull-Tabs ❑ *Tfpboaeds <br />�` Gam6ling �qui�mertt for pt�ll-tabs, tipi�oards, paddtewheels, �nd fiingo (hingo paper, <br />hard cards, and bingo number select9on device} mus# he obtairsed frorn a cfiskributor <br />llcensed by the Garnbiing Corrtrol Board, To Flnd a licen�ed dis#�ibutor, go to <br />www.gcb.staCe.mn.us and clicic on Llst of Licenseci Distrib�rtors, or c8ll 65Z-639-4Q76. <br />