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Minnesofa Lawful Gambling <br />LG220 Application for Exemp� Permit <br />A,n �xempt per�rnit may be issued fo a nonproFt organization thai: <br />- conducts lawfe�l gaml�ling on frve or fewe.r days, and <br />- awards less tt�an $50,OOp in priz.es cfuring a cafendar year: <br />RGANlZATfQN INFORtVIAT14N <br />Organization name <br />Attachment A <br />1 of 2 7109 <br />less tha� 30 days more fhan 3Q days <br />before the event before tY�e evenf <br />$100 $50 <br />Check # $ <br />Previous gamblir�g p�rrr�it number <br />.�(.�l ` i'IOC.. i.. L%-r 57? GC �'1 1� I C' ff� _`� �C7 �i <br />iype of non}�rafit organization. Check ane. <br />� Fratemal � Reiigious � Veterans � Other nonproft# arganizatioi� <br />Mail�ng add.ress City State Zip Code County <br />:� ���� ��.i �t/ �� zv �/[. h� �?,S�' v'1 C I�, i7� n1 � S'�,3 l�- i�� �. -. <br />Name of chief ezecutive afficer (CEO) Daytime phone nu.rr�ber �mail address <br />�i� r LI"l�il1� ! �'7L'rn�7Sc�r) � � 1—`��"�!'7�� 1 /f-.1: (�CNP�S;Z� rrlc',�v'�ss �L �• <br />Attac�t a copy of ONE of the folfowing for pranf ofi nonprofit siatus. Check one. <br />Do not aitach a sales tax exempt 5tatus or fEderal ID empEoyer �umber5 as they are not propf of nonprofit status. <br />❑�lonprofit ArticEes af Incarporatior� OR a current Certificate of Good 5tanding. <br />Don't ha�e a copy? 7his certificate me�st ba obtained each year from: <br />5ecrefary of Siate, Business Services Div., 1$fl 5iafe Office Building, St. PauE, MN 55155 Phone: 651-296-28�3 <br />�- IRS income tax ex�mptio� [509[c�� IeL4er in your organizatiort's name. <br />Don't have a copy? Ta obtain a copy af your #ederal income tax exempt lef#er, ha�e an organiza#ion officer <br />contaet the IRS at 877-829-550D. <br />� IR5 -AfEiliat� of hational, statewid.e; ar international parent nanprof�t organization (charter) <br />If yolir organiza#ion falls u�der a parent ar�anizatior�, at#ach co�ies of 6oth of the falEowing: <br />a: IRS letfer showing yo�r parent organization is a no�profit 501(c} organization with a grou� ruling, and <br />b. the char#er or [efter fmrr[ your parent organization recbgnizing yaur organization as a subardinate. <br />� IRS - proof pre�ious4y submitted ta Gambling Gontrol Board <br />If yau �arevinusly submii#ed proof of nonprofit status firorn ihe IRS, no afiachmeni is required. <br />GAMBLING PREMISES �NFORMATION <br />Name of premises vvhere gamhling activity wili be conducted (€or raf�ies, list #h� site where ihe drawing will iaice place) <br />� r� f� r, / / <br />(1���[� �'E� �til.�t�t� ��L� _��✓��3 �Y',,.'..'�T�" C�/�v''G � <br />Address (do not �rse PO box) �� City Zip Code Couniy <br />_-`� 1��� �=��,��i �/� t c;v 1�le �1 �SG i!r 1 �� f"r1 !�1 S�/13 �u rv� S C � <br />Qate(s) af activity (for raffles; indicate #he date of ihe drawing) <br />i i � Z `I' �C'f <br />:k ihe box or boxes that indicate ths type oi gamblir�g activity your organizafion will conctuct: <br />� Binga' �Raffles �paddlewheeis" �Pull-Tabs" �Tipboards' <br />* Garrtbling equipment for p�ll-tabs, bingo paper, tipboards, ar�d <br />�addfewheels must be obtaine� from a distributor l4censed by the <br />Gambli�g Control Baard. E7CCEPTION: BRngo hard cards and bingo <br />number selecliorr devices may be borrowed frorri another organization <br />authorized to conduct bingo. <br />To find a licensed cfistributor, go to www.gcb.sta�e.mn.us and cEick on L,ist <br />c�f Licensed �istrib�tors, or call 651-539-407b. <br />Aiso campfete <br />Page 2 of this form. <br />Print Form <br />Reset Form <br />ca5`�`-� �'��` <br />