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MINNESOTA LAWFUL GAMBLING <br />LG220 Application for Exempt Permit <br />An exempt permit may be issued to a nonprofit <br />organization that: <br />conducts lawful gambling on five or fewer days, and <br />awards less than $50,000 in prizes during a calendar <br />year. <br />If total raffle prize value for the calendar year will be <br />$1,500 or less, contact the Licensing Specialist assigned to <br />your county by calling 651-539-1900. <br />ORGANIZATION INFORMATION <br />671, .5 <br />4/17 <br />Page 1 of 2 <br />Application Fee (non-refundable) <br />Applications are processed in the order received. If the application <br />is postmarked or received 30 days or more before the event, the <br />application fee is $100; otherwise the fee is $150. <br />Due to the high volume of exempt applications, payment of <br />additional fees prior to 30 days before your event will not expedite <br />service, nor are telephone requests for expedited service accepted. <br />Organization b m Previous Gambling <br />Name: _!tel �� 4 �14A f4 I Z3 r4!5V6 �Irlry Permit Number: h <br />Minnesota Tax ID <br />Number, if any: _ <br />Federal Employer ID <br />Number (FEIN), if any: <br />Mailing Address: 4 d DG4, <br />r <br />City: �- �% State: A Zip: tZ_ County: <br />r- / <br />Name of Chief Executive Officer (CEO): A o�� ��ir�d7'�� — LaCsL-f— e�'aAtre--✓1 ti! A rte-- t' <br />Daytime Phone: �o ti - �!/ C (:� fl (v Email: jkpkZ� 6 <br />NONPROFIT STATUS <br />Type of Nonprofit Organization (check one): <br />JSpe,ib &-v <br />Fraternal Religious Veterans Other Nonprofit Organization <br />Attach a copy of 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 />A current calendar year Certificate of Good Standing <br />Don't have a copy? Obtain this certificate 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 />IRS income tax exemption (501(c)) letter in your organization's name <br />Don't have a copy? To obtain a copy of your federal income tax exempt letter, have an organization officer contact the <br />IRS toll free at 1-877-829-5500. <br />IRS - 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 />GAMBLING PREMISES INFORMATION <br />Name of premises where the gambling event will be conducted <br />(for raffles, list the site where the drawing will take place): AA16d <br />Physical Address (do not use P.O. box): a o 1 b kc O ki-44'k- <br />,I <br />City or Township: '� i rU4Xjkre-1— Zip: County: t� � <br />Date(s) of activity (for raffles, <br />indicate the date of the drawing): t <br />Check each type of gambling activity that your organization will conduct: <br />=Bingo Paddlewheels Pull -Tabs =Tipboards <br />171 Raffle (total value of raffle prizes awarded for the calendar year, including this raffle: $D DDD } <br />Gambling equipment for bingo paper, bingo boards, raffle boards, paddlewheels, pull -tabs, and tipboards must be obtained <br />from a distributor licensed by the Minnesota Gambling Control Board. EXCEPTION: Bingo hard cards and bingo ball selection <br />devices may be borrowed from another organization authorized to conduct bingo. To find a licensed distributor, go to <br />www.mn.gov/gcb and click on Distributors under List of Licensees, or call 651-539-1900. <br />