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MINNESOTA LAWFUL GAMBLING <br />LG240B Application to Conduct Excluded Bingo <br />6/13 Page 1 of 2 <br />No Fee <br />OR.GANIZATION INFORMATION <br />Organization name Previous gambling permit number <br />Saint John's Church of Little Canada XB -62005-14-005 <br />Minnesota tax ID number, if any Federal employer ID number (FEIN), if any <br />ES 23330 41-0781158 <br />Type of nonprofit organization. Check one. <br />Fraternal X Religious Veterans Other nonprofit organization <br />Mailing address City State Zip code County <br />380 Little Canada Road Little Canada Minnesota 55117 Ramsey <br />Name of chief executive officer [CEO] Daytime phone number • E-mail address <br />Rev. Thomas Balluff 651 484-2708 pastor@stjohnsof1c.org <br />,NONPROFIT STATUS <br />Attach a copy of ONE of the following for proof of nonprofit status. <br />x Nonprofit Articles of Incorporation OR a current Certificate of Good Standing. <br />Don't have a copy? This certificate must be obtained each year from: <br />Secretary of State, Business Services Div., 60 Empire Drive, Suite 100, St, Paul, MN 55103 <br />Phone: 651-296-2803 <br />IRS income tax exemption [501(c)] Tetter in your organization's name. <br />Don't have a copy? To obtain a copy of your federal income tax exempt letter, have an organization <br />officer contact the IRS at 877-829-5500. <br />IRS - Affiliate of national, statewide, or international parent nonprofit organization [charter] <br />If your organization falls under a parent organization, attach copies of both of the following: <br />a. IRS letter showing your parent organization is a nonprofit 501(c) organization with a group ruling, and <br />b. the charter or letter from your parent organization recognizing your organization as a subordinate. <br />EXCLUDED BINGO ACTIVITY <br />1. X No Yes Has your organization held a bingo event in the current calendar year? <br />If list the dates when bingo was conducted. <br />yes, <br />2. The proposed bingo event will be: <br />X one of four or fewer bingo events held this year. Dates _ Noyernlier.....2l ,._2015 <br />OR <br />conducted on up to 12 consecutive days in connection with a: <br />county fair. Dates <br />_ <br />civic celebration. Dates <br />Minnesota state fair. Dates <br />3. Person in charge of bingo event Rev. Thomas Balluff Daytime phone 651 484-2708 <br />4. Name of premises where bingo will be conducted school gymnasium <br />5, Premises street address 2621 McMenemy Street <br />6. City Little Canada If township, township name County J.auts_ay <br />Bingo hard cards and bingo number selection devices may be borrowed from another organization authorized <br />to conduct bingo. Otherwise, bingo hard cards, bingo paper, and bingo number selection devices must be obtained <br />from a distributor licensed by the Minnesota Gambling Control Board. To find a licensed distributor, go to <br />www.gcb.state.mn.us and click on Distributors under the WHO'S WHO? LIST OF LICENSEES, or call <br />651-539-1900. Be sure to complete page 2 <br />r� <br />J <br />r: <br />