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LG220 <br />(Rev. arises) <br />Minnesota Lawful Gambling <br />Application for Authorization for <br />Exemption from Lawful Gambling License <br />Fill in the unshaded portions of this application for exemption and <br />send it in at /east 45 days before your gambling activity for processing. <br />Name and Address of Organization <br />FOR BOARD USE ONLY <br />FEE CHK <br />INIT DATE <br />Organization Name / <br />.s T SOS € ri <br />Street City <br />)71 6/� S�R�v7 L, L.cXE.s <br />Chief Executive Officer Dayt Phone Number <br />Current/previous license number <br />Current/previous exempt number <br />i< 7 /744-3.0i(6/ 04)5Type of Non-profit Organization <br />State <br />1012 <br />Treasurer <br />Zip code <br />5-50/y <br />1 n a!l t'S A q S' c <br />County <br />Daytime Phone Number <br />(1,40 78o "c /o ' <br />Check the box below which indicates your type of organization <br />El <br />Fraternal <br />Veterans <br />Religious <br />Other non-profit <br />Gambling Site <br />Name of site where activity will take place <br />vi9m fJ5 ,9,r7oc3 <br />Check the box that indicates your proof of nonprofit <br />status and attach a copy of the proof to the application. <br />❑ IRS designation <br />(x' Certification of good standing from the Minnesota <br />Secretary of State's office <br />❑ Affiliate of parent nonprofit organization (charter) <br />Street City <br />Township <br />State <br />MN <br />Zp code <br />County <br />Date(s) of activity (for raffles, Indicate the date o1 the drawing) <br />4tiu_5 i.+/3, 7- <br />Typehof Games <br />Game(s) Gross Receipts <br />Financial Report <br />Expenses, including <br />Cost of Prizes <br />Market Value of Prizes <br />(Including Donations <br />and cash) <br />Bingo <br />Raffles <br />Paddlewheels r'J <br />Tipboards �1 <br />Pull -tabs <br />I declare all information submitted to the <br />Gambling Control Board is true, accurate, <br />and complete. <br />1 dedare ail financial information submitted to the:Gambiti <br />Board Is true, accurate, and complete. <br />Control <br />Chief Executive Officer's Signature <br />Local Unit of Government Acknowledgment <br />Date Chief Executive Officer's: Signature <br />I have received a copy of this application. This application will be reviewed by the Gambling Control Board and will become effective 30 days from the date of <br />receipt by the city or county, unless the local unit of government passes a resolution to specifically prohibit the activity. A copy of that resolution must be received <br />by the Gambling Control Board wlthin 30 days of the date filled in below. Cities of the first dass have 60 days in which to disallow the activity. <br />City or County <br />Township <br />City of county name Q <br />Signatur o1 n oeiving application <br />Date received <br />613o <br />Title <br />Ube <br />(12,E <br />This form will be made available <br />in alternative format (i.e. large <br />print, braille) upon request. <br />Township name <br />Signature of person receiving application <br />Title <br />Date Received <br />it with $25 permit fee and copy of <br />proof of nonprofit status to: <br />Gambling Control Board <br />1711 W. County Rd. 8, Ste. 300 S. <br />Roseville, MN 55113 <br />Township is <br />❑ organized <br />❑ unorganized* <br />❑ unincorporated* <br />Attach letter <br />White - Original <br />Yellow - Board retums to <br />Organization to complete <br />shaded areas <br />