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Minnesota Lawful Gambling <br />Page 1 of 2 6/08 <br />LG220 Application for Exempt Permit <br />For Board Use Only <br />Check#__ <br />An exempt permit may be issued to a nonprofit organization that: Fee is $50 for <br />• conducts lawful gambling on five or fewer days, and <br />• awards less than $50,000 in prizes during a calendar year. each event <br />$ <br />ORGANIZATION INFORMATION <br />Organization <br />name- � <br />/)E X �/(Z 7:6-7,1« lecIA)5) /J .) <br />Previous gambling permit number <br />" ._ /. / s -72 <br />Type of nonprofit organization. Ch ck (4) one. <br />❑ Fraternal [—j Religious ❑ Veterans 1 ..Other nonprofit organization <br />Mailing address. <br />c-- /. krAcm ft. to ,,K/ <br />City _ <br />A. / 6 50,40.4.- <br />Code <br />fi91) "still <br />County <br />Name of le executive officer (CEO) <br />JE. , ti3 /04c? [) <br />Daytime phone number <br />- o- Y/ /, 0 <br />ATTACH A COPY OF ON OF THE FOLLOWING FOR PROOF OF NONPROFIT STATUS <br />* Do not attach a sales tax exempt <br />___ Nonprofit Articles of Incorporation <br />Don't have a copy? This <br />Secretary of State, Business <br />_ Internal Revenue Service <br />Don't have a copy? To <br />contact the IRS at 877- <br />_.__Internal Revenue Service - <br />If your organization falls <br />a. IRS letter showing your <br />b. the charter or letter <br />internal Revenue Service - <br />if you previously submitted <br />status or federal ID employer numbers as they are not proof of nonprofit status. <br />OR a current Certificate of Good Standing. <br />certificate must be obtained each year from: <br />Services Div., 180 State Office Building, St. Paul, MN 55155 Phone: 651-296-2803 <br />- IRS income tax exemption [501(c)] letter in your organization's name. <br />obtain a copy of your federal income tax exempt letter, have an organization officer <br />829 -5500. <br />Affiliate of national, statewide, or international parent nonprofit organization (charter) <br />under a parent organization, attach copies of both of the following: <br />parent organization is a nonprofit 501(c) organization with a group ruling, and <br />from your parent organization recognizing your organization as a subordinate. <br />proof previously submitted to Gambling Control Board <br />proof of nonprofit status from the Internal Revenue Service, no attachment is required. <br />GAMBLING PREMISES INFORMATION <br />Name of premises where gambling activity_will be conducted (for raffles -list the site where the drawing will take place) <br />Address (do not use box) ' <br />/i (, 7/? 7/N)9` )&_ <br />City <br />l / " ('4/u4 <br />Zip Code <br />rs // 7 <br />-Cqunty <br />Kr1/` J <br />Date(s) of activity (for raffles, indicate the d to o t e drawing <br />Check the box or bo es that indicate the type of gambling activity your organization will conduct: <br />❑ "Bingo . Raffles ❑ "Paddlewheels ❑ "Pull -Tabs ❑ " Tipboards <br />* Gambling equipment for pull -tabs, bingo paper, tipboards, and paddlewheels must <br />be obtained from a distributor licensed by the Gambling Control Board. <br />EXCEPTION: Bingo hard cards and bingo number selection devices may be borrowed <br />from another organization authorized to conduct bingo. <br />To find a licensed distributor, go to www.gcb.state.mn.us and click on List of Licensed <br />Distributors, or call 651- 639 -4076, <br />2 <br />