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Minnesota Lawful Gambling <br />LG220 Applicafiion �or Exempt Permit <br />An ex.empt permit may be issued to a nonprofit arganixation that: <br />- conducts lawful ga.mi�ling on five or fewer days, and <br />- awarc{s less than $50,000 in prizes durin� a calendar year. <br />RGANIZATION INFORMATION <br />Attachment A <br />1 of 2 7109 <br />fess than 30 days more than 30 days <br />beiora fhe ever�t before the event <br />$1DU $50 <br />Gheck # �,�' aJ /� $ <br />Organizat'son name Previous gambling permit number <br />Type of nonpcofit organization. C�eek one. <br />�. Fraternal � R�ligious � Veterans �❑ Ot�er nonprofit orga�ization <br />Maifing address City State Zip Cnde County <br />Name of chief executive afFc�r (C��) <br />Qaytime phone number <br />Email address <br />Attach a capy of ON� of th� following for proof of nonprofit status. Ch�ck one. <br />Da not attach a sales tax exempt s�atus or federal Tb err�ployer numbers as they are not proof of nonprofit status. <br />�Nonprofit Arficies af Incorporation OR a current Certificate of Cood 5tanciing. <br />Don'# ha�e a copy? This certificate must be obtained each year from: <br />Secretary ofi 5tate, 8usiness Services aiv., 180 5tate Qf#'sce $uilciing, St. Paul, IV�N 55155 Phone: 651-296-28d3 <br />� 1FtS inGOme tax exempiion [501(c)] letter in your organization's name. <br />Don'i have a copy? To obtain a copy af your federal income tax exempf letter, have an organizatian oificer <br />contact the IRS at 877-829-5500. <br />�!RS -Affiliat� of national, staiewide, or inteenational parent nonprofit organization (cha.rier} <br />If your organization falEs under a parent arganizatian, attacft copies of both of the following; <br />a. IFiS letter sh.owing your parent organization is a nanprofit 501{c) organizatian with a group ruling, and <br />b. the char�er or letter from your parent organization r�cogni:zing your organization as a subo�dinafe. <br />� IR5 - proof previousEy submitted to Gambling Control Board <br />If you p�eviously submitted proof af nonprofit status'fram the IRS, no affachment is req[tired. <br />GAMBLI�VG PREMISES INFORMAT[ON <br />Name of premises where gambling activity wilf he con.ciucted {for raffles, lis{ fhe site where #he drawing wi[I take place) <br />{do no't use PO box) <br />pate(s) of activity (for raf€ies, indicate the date of the drawing} <br />City <br />Zip Code Caunty <br />�ck fhe pox o� boxes ihat indicate the type of gambl.ing acti�ity your organization will conduct: <br />�Bingo* �Ra#fles �Paddlewheels' �PU.II-Tabs* �iipboards* <br />* Gambling eguipment for pull-tabs, bingo paper, tipboards, and <br />paddlewheefs must be abtained fram a distrihutor licensed by the <br />Gambiing Control 8oard: EXCEPTION: Singo hard cards and bingo <br />number setectian devices may be borrowed from anotiher organization <br />authorized to conduct bingo. <br />To fnd a licensed distributor, go to www.g.cb.state,mn.us and click on List <br />of �icensed. Distr�butars, ar ca[I 651-639-4�76, <br />Also ccsmplete <br />Page 2 of this form. <br />�ill-in & Print Form <br />Reset Fo�m <br />�-�rrn� <br />n�� <br />