2016.12.19 CC Packet - Laserfiche WebLink

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MINNESOTA LAWFUL GAMBLING LG220 Application for Exempt Permit 12/16 Page 1 of 2 An exempt permit may be issued to a nonprofit Application Fee (non-refundable) organization that: Applications are processed in the order received. If the application • conducts lawful gambling on five or fewer days, and is postmarked or received 30 days or more before the event, the • awards less than $50,000 in prizes during a calendar application fee is $100; otherwise the fee Is $150. year. If total raffle prize value for the calendar year will be Due to the high volume of exempt applications, payment of $1,500 or less, contact the Licensing Specialist assigned to additional fees prior to 30 days before your event will not expedite your county by calling 651-539-1900. service, nor are telephone requests for expedited service accepted. ORGANIZATION INFORMATION Organization Church of St. Genevieve Previous Gambling X-98008-16-012 Name: Permit Number: Minnesota Tax ID Federal Employer ID Number, if any: 4361808 Number (FEIN), if any: 41-1417861 Mailing Address: 7087 Golffon Rd City: Centerville_ _ state: MN zip: 55038 _ County: Anoka_ Name of Chief Executive Officer (CEO): Fr. Greg Est Daytime Phone: 651-429-7937 Email: _gesty@stgens.org NONPROFIT STATUS Type of Nonprofit Organization (check one): = Fraternal 0 Religious Veterans Other Nonprofit Organization Attach a copy of one of the following showing proof of nonprofit status: (DO NOT attach a sales tax exempt status or federal employer ID number, as they are not proof of nonprofit status.) 0 A current calendar year Certificate of Good Standing Don't have a copy? Obtain this certificate from: MN Secretary of State, Business Services Division Secretary of State website, phone numbers: 60 Empire Drive, Suite 100 www.sos.state.mn.us St. Paul, MN 55103 651-296-2803, or toll free 1-877-551-6767 IRS income tax exemption (501(c)) letter in your organization's name Don't have a copy? To obtain a copy of your federal income tax exempt letter, have an organization officer contact the IRS toll free at 1-877-829-5500. �✓ IRS - Affiliate of national, statewide, or International parent nonprofit organization (charter) If your organization falls under a parent organization, attach copies of both of the following: 1. IRS letter showing your parent organization is a nonprofit 501(c) organization with a group ruling, and 2. the charter or letter from your parent organization recognizing your organization as a subordinate. GAMBLING PREMISES INFORMATION Name of premises where the gambling event will be conducted (for raffles, list the site where the drawing will take place): St John Site of St Genevieve Church Address (do not use P.O. box): 14383 Forest Blvd N City or Township: Hugo Zip: 55038 County: Washington Date(s) of activity (for raffles, Indicate the date of the drawing): _March 3 10 17 24 31 A r€I 7 2017 Check each type of gambling activity that your organization will conduct: =Bingo Paddlewheels =Pull -Tabs =Tipboards Raffle (total value of raffle prizes awarded for the calendar year, including this raffle: $ est. S 5350.00 ) Gambling equipment for bingo paper, bingo boards, raffle boards, paddlewheels, pull -tabs, and tipboards must be obtained from a distributor licensed by the Minnesota Gambling Control Board. EXCEPTION: Bingo hard cards and bingo ball selection devices may be borrowed from another organization authorized to conduct bingo. To find a licensed distributor, go to www.mn.gov/gcb and click on Distributors under List of Licensees, or call 651-539-1900.