2017.01.03 CC Packet - Laserfiche WebLink

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MINNESOTA LAWFUL GAMBLING LG220 Application for Exempt Permit 4.1 � 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 O anizatioA�Previous Gambling Name: d9 J SA*4 �O4UA4 Q«J Permit Number: S?d1-G -ab Minnesota Tax ID Federal Employer ID Number, if any: �� %�12g��y� Number (FEIN), if any: Mailing rI Ndrk �'. ©�L�r ! 38fa Y S /y Address• �- City: _�� /i.:i State': � Zip: Z County: Name of Chief Executive' Officer (CEO):L�'+ f L Daytime Phone: to 6 — .2 y5- �L Email: ISi Ds LG CIISr. AXT NONPROFIT STATUS , Type of Nonprofit Organization (check one): ' Fraternal Religious Veterans Other Nonprofit Organization Attach a copy of 4115 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.) 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.stift 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 bgjh 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):/�1L� Address (do not use P.O. box): 1 010 !.f f� I City or /, f/JYaft) , %�%� 21 ri� 2 County: _4 14-.11 lt44 Township: p: �� Date(s) of activity (for raffles, indicate the date of the drawing): f{kyyticf 1-61 7DI Check each type of gambling activity that your organization will conduct: =Bingo =Paddlewheels Pull -Tabs =Tipboards Raffie (total value of raffle prizes awarded for the calendar year, including this raffle: $ 1 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.