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Minnesota Lawful Gambling <br />ation to Conduct Excluded Bingo <br />6/07 <br />Page 1 of 2 <br />No fee <br />ORGANIZATION INFORMATION <br />Organization name <br />G 'DI D144); _-,Je, <br />Prevous ambling permit number <br />! 4oa /9 <br />Pk Other nonprofit organization <br />Type of nonprofit organization. Check (1l) one. <br />n Fraternal 7 Religious ❑ Veterans <br />Mailing address <br />- UTggg A gad <br />City State /Zip ode [ C my <br />L/mgC 1/A) (9/71 7690 5 �y <br />, <br />ATTACH A COPY OF ONE OF THE FOLLOWING FOR PROOF OF NONPROFIT STATUS <br />* Do not <br />* Nonprofit <br />attach a sales tax exempt status or federal ID <br />Articles of Incorporation OR a current Certificate <br />have a copy? This certificate must be obtained <br />of State, Business Services Div., 180 <br />Revenue Service - IRS income tax exemption <br />have a copy? To obtain a copy of your federal <br />date your organization initially applied for tax <br />P.O. Box 2508, Room 4010. Cincinnati, <br />Service - Affiliate of national, statewide, <br />organization falls under a parent organization, <br />letter showing your parent organization is <br />charter or letter from your parent organization <br />Service - proof previously submitted <br />previously submitted proof of nonprofit status <br />employer number as they are not proof of nonprofit <br />of Good Standing. <br />each year from: <br />State Office Building, St. Paul, MN 55155 Phone: 651 <br />[501(c)] letter in your organization's name. <br />income tax exempt letter, send your federal ID number <br />exempt status to: <br />OH 45201 <br />or international parent nonprofit organization <br />attach copies of both of the following: <br />status. <br />- 296 -2803 <br />and <br />(charter) <br />is required. <br />Don't <br />Secretary <br />Internal <br />— <br />Don't <br />the <br />IRS, <br />Revenue <br />_Internal <br />If your <br />a. IRS <br />b. the <br />Revenue <br />a nonprofit 501(c) organization with a group ruling <br />recognizing your organization as a subordinate. <br />to Gamblng Control Board <br />from the Internal Revenue Service, no attachment <br />_Internal <br />If you <br />EXCLUDED BINGO ACTIVITY <br />1. AA` No _Yes <br />2. The proposed <br />i one of <br />_conducted <br />3. Person in <br />4. Name of premises <br />5. Premises <br />s <br />r <br />6. City 0 inf. <br />Has your organization held a bingo <br />If yes, list the dates when bingo was <br />bingo event for which we are applying <br />four or fewer bingo events held this year. <br />OR <br />up to 12 consecutive days in connection <br />county fair. Dates <br />event in the current calendar year? <br />conducted <br />will be: <br />Dates g 0 — `— <br />/ 9 <br />with a: <br />civic celebration. Dates <br />Minnesota state fair. Dates <br />}fit/ <br />charge of bingo event (: fi ticK "(Clf Mf}+,Vp� IC6(412Q Daytime phone 60-M6-031f <br />where bingo will be conducted 5.rf DOA/ P,?t � <br />street address so eL, km° <br />� /g <br />t c C777wfO/tJ MA) If township, name of township County Jet4 5ey <br />Bingo hard cards, bingo paper, and bingo number selection devices must be purchased <br />from a distributor licensed by the Gambling Control Board. To find a licensed distributor, go <br />to www.gcb.state.mn.us and click on List of Licensed Distributors. Or call 651 - 639 -4076. <br />Iv04 26E" )0� / CEQ )'- /©t,�a6U <br />Tit/is UI rLC �� A <br />LLD Dute/NG GAM-PO Dlkfl- ThsriVa -4 . 4c PR 12£6 <br />9Moe thge00 �0Nf} '..O {' LI 4,iJ -C 7 a,rn ESSES - 5PE 4 tAcHEd <br />Ci ftD <br />