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MINNESOTA LAWFUL GAMBLING <br />11/17 <br />LG240B Application to Conduct Excluded Bingo No Fee Page 1 of 2 <br />ORGANIZATION INFORMATION <br />Organization Previous Gambling <br />Name: Mounds View Police Foundation Permit Number: <br />Minnesota Tax ID Federal Employer ID <br />Number, if any: Number (FEIN), if any: 81-4446937 <br />Mailing Address: 9422 Ulysses Street NE, Suite 120 <br />City: Blaine State: MN Zip: 55343 County: Anoka <br />Name of Chief Executive Officer (CEO): Katrina Joseph <br />CEO Daytime Phone: 612-787-7698 CEO Email: katrina@hjlawmn.com <br />(permit will be emailed to this email address unless otherwise indicated below) <br />Email permit to (if other than the CEO): <br />NONPROFIT STATUS <br />Type of Nonprofit Organization (check one): <br />Fraternal Religious Veterans �✓ Other Nonprofit Organization <br />Attach a copy of at least one of the following showing proof of nonprofit status: <br />(DO NOT attach a sales tax exempt status or federal employer ID number, as they are not proof of nonprofit status.) <br />Current calendar year Certificate of Good Standing <br />Don't have a copy? This certificate must be obtained each year from: <br />MN Secretary of State, Business Services Division Secretary of State website, phone numbers: <br />60 Empire Drive, Suite 100 www.sos.state.mn.us <br />St. Paul, MN 55103 651-296-2803, or toll free 1-877-551-6767 <br />Internal Revenue Service -IRS income tax exemption 501(c) letter in your organization's name <br />Don't have a copy? Obtain a copy of your federal income tax exempt letter by having an organization officer contact <br />the IRS at 877-829-5500. <br />Internal Revenue Service -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 />1. IRS letter showing your parent organization is a nonprofit 501(c) organization with a group ruling; and <br />2. the charter or letter from your parent organization recognizing your organization as a subordinate. <br />EXCLUDED BINGO ACTIVITY <br />Has your organization held a bingo event in the current calendar year? Yes �✓ No <br />If yes, list the dates when bingo was conducted: <br />The proposed bingo event will be: <br />one of four or fewer bingo events held this year. Dates: <br />-OR- <br />conducted on up to 12 consecutive days in connection with a: <br />county fair Dates: <br />�✓ civic celebration Dates: 8/19/2023 <br />1-1 Minnesota State Fair Dates: <br />Person in charge of bingo event: Katrina Joseph Daytime Phone: 612-787-7698 <br />Name of premises where bingo will be conducted: Mounds View Silver View Park <br />Premises street address: 2700 County Road I, Mounds View, MN 55112 <br />City: Mounds View If township, township name: County: Ramsey <br />