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� <br />Minne�sota Lawful Gambling <br />LG220 Applica�ion for Exempt Permit <br />An exerrtpt permit may be issued to a nonpr�fit organization that: <br />- conducts lawful gambGing on five or fewer days, and <br />- awards less fhan $50,OOa in prizes during a ca�endar year. <br />ORGANI.ZATION INFORMATION Check# <br />Organization name <br />��� ''�..��. <br />` G�( �n. <br />Type of nanprofi# organization. Check one. <br />�❑ Frafernal ❑❑ Religiaus �Veterans <br />Mailing address City <br />� �;E � 1 ! � � � � 1- <br />tVam� of chief execuiive a�cer (CEC�.� <br />.5 a .- f <br />Attachment A <br />Page' 1` bf 2 7l09 <br />iication fee <br />less'than 30 days <br />bafare the event <br />$100 <br />$ <br />more than 30 days <br />before the event <br />$50 <br />Previous gambling permii nurnber <br />�I I t�� <br />� Other noi�profit organization <br />State Zip Code ,.� Counfy <br />(i+�} f . . � `�' �� � 4 � <br />Daytime phane number Email address <br />��� A � r �� `� �"�j�2� <br />Aitach a copy of ONE of the foll�o ing far proof of nonpr�fit siatus. Check one. <br />Da not a€�ach a sales tax exempt status or federaf ID er�rpfoyer numbers as t1�ey are not proof of nonprofit status. <br />��fanpro#it Ariicles of Incorporatipn OR a cutrent Certifi�ate of Gaod Standing. <br />� W� Don't have a copy? �his cerfificat� must be obtained each year from: <br />Secretary of State, Business Services Div., 180 5tate Office Building, St. Paul, NiN 55155 Phone: 65"I-296-2803 <br />� fRS in�ome tax exemptior� [5D7(c)] letter in your organization's name. <br />�on't have a copy? To obtain a copy af your federal income tax exerr�pt ]etter, have an organizaiion officer <br />cantact the IF�S at 877-829-5500. <br />� IR5 - Affiliate of national, statewide, or international parent nonprofit organization (chartefj <br />If your organization falls under a parent organization, atfach copies of both of the following: <br />a. IRS lefter showing your parent organization is a nonprofif 501(c) organization with a group ruling, and <br />b, the charter o� letter from your parent organizatian recognizing your arganization as a subordinate. <br />❑❑ ERS - praof previously submitted to Gambling Control 8oard <br />If you previously submitfed proof of nonpro�it status from the tRS, no attachrnent is required. <br />GAMBLING PREMISES ENFORMATION <br />lVarne of premises where gambling activity will be conducted (for raffles, list the site where the drawing wiil take place) <br />� `(.���� �`��,c�,� C.��,� �� <br />Address (da not use PO box) Cify Zip Code County <br />Z� ���d �!� C �-��' tJ1�. �� ����� �i� � �� ` .-�i�'�-t <br />Date.(s) of activity (for raffles, indicate the date of the dt�awing} <br />�� Ol �- � �� ��.� �3 �j <br />;heck the box or �oxes that indicate the type oi gamhling activity your organization wili conduct: <br />� Bingo" �affles � Paddlewheels' [�'Pull-Tabs' �}Tipboards" <br />*(Cambling equipment for pull-tabs, bingo paper, tipbaards, and <br />paddlewheels must be obtained from a distributor licensed by the <br />Gambling Contral Board. �XCEPTION: Bingo hard cards and bingo <br />nurnber sefection devices may be borrowed from another organiza.tion <br />authorized to conduct bingo. <br />To find a licensed distributar, go to www,gcb.state.mn.us and. click on �ist <br />of Licensed Distrihutors, ar c�ll 651-639-4076. <br />Also compEete <br />Page 2 of this farm: <br />Fill-in & Print Form <br />ResetForm <br />