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CG220 Minnesota Charitable Gambling <br />(Rev. 3/69) Application for Exemption from <br />Charitable Gambling License <br />Fill in the unshaded portions of this application for exemption and send it in at least 45 days before your gambling activity for processing. <br />Name and Address of Organization <br />For Office Use Only <br />Organization <br />currenUprevious license number <br />currenUprevious exempt number <br />Strj city Slate Zip code County <br />Tt c 5o% / %©I� J`%r f"lfv �� /l) � f Sly <br />ecu a er Phone Manager <br />Phone <br />Type of No -pit rofit Organization <br />Years in existence . Attach proof of three -years or more of existence. Number of active members <br />❑ Fraternal ❑ Religious ❑ Veterans ❑ Other non - profit <br />If you checked box for other nonprofit, check one of the following and attach proof of nonprofit status <br />❑ IRS designation ❑ Incorporated with Secretary of State ❑ Affiliate of parent nonprofit organization (charter) <br />Gambling Site <br />Name of site where activity will take place <br />✓ l77 7W/C/ <br />Stre- City State Zip code County <br />Date(s) of activity <br />tc/ G L i'LLf Cfi�H-a• 5� rl Sde7_ <br />Types of Games <br />Game <br />Yes No <br />Bingo ❑ ❑ <br />Raffles ❑ ❑ <br />Paddlewheels ❑ ❑ <br />Tipboards ❑ ❑ <br />Pull -tabs ❑ ❑ <br />rose receipts . <br />Financial Report <br />Expenses, including Net profit <br />Cost of Prizes <br />Market Value <br />°.:ot Prizes -. <br />How will profit be used: <br />Distributor from whom gambling - equipment purchased <br />Distributors license number <br />declare all information submitted to the Department of Revenue <br />is true accurate, and complete <br />''declare all information submitted to the. Department of Revenue <br />is true, accrate, and complete <br />Chief executive officer's signature <br />Date Chief executive officers signature <br />Date <br />Local Government Acknowledgement <br />I have received a copy of this application. This application will be reviewed by the Department of Revenue and will become effective 30 days <br />from the date of receipt by the city or county, unless the local government passes a resolution to specifically prohibit the activity. A copy of that <br />resolution must be received by the Department of Revenue within 30 days of the date filled in below. <br />City or County City of I ittle Canada <br />City or county name <br />Township <br />Township name <br />'g • o p- on receivi g app 'canon <br />lerk- Treasurer <br />Title <br />Date r <br />eceiv <br />5l1/fl9 <br />gnature o person receiving app 'cation <br />Title <br />Date received <br />While - Board <br />Pieta— Oedema/than <br />Yellow— Bo mimes tians to Organization to <br />a <br />pele medal areas <br />Gold —City a Camay <br />Mail this application to: <br />Department of Revenue — Gaming Division <br />Mail Station 3315 <br />St. Paul, MN 55146 -3315 <br />PAGE -1- <br />