2019.03.04 CC Packet - Laserfiche WebLink

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MINNESOTA LAWFUL GAMBLING LG220 Application for Exempt Permit 6-.-5 11/17 Page i of 2 An exempt permit may be issued to a nonprofit Application Fee (non-refundable) organization that: gambling on five or fewer days, and Applications are processed in the order received. If the application . conducts lawful gam awards less than $5 Ming in prizes during a calendar is postmarked or received 30 days or more before the event, the • year. application fee is $100; otherwise the fee is $150. 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 Previous Gambling Name: White Bear Lake HS Boys Lacrosse Booster Club Permit Number: Minnesota Tax ID Federal Employer ID Number, if any: Number (FEIN), if any: 83-3600601 Mailing Address: 2312 Tart Lake Road City: Lino Lakes State: MN Zip: 55038 County: Anoka Name of Chief Executive Officer (CEO): Mark Woodcock CEO Daytime Phone: 651-274-3046 CEO Email: mndwoody@comcast.net (permit will be emailed to this email address unless otherwise indicated below) Email permit to (if other than the CEO): NONPROFIT STATUS Type of Nonprofit Organization (check one): = Fraternal = 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.) 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): Hugo American Legion Post 620 Physical Address (do not use P.O. box): 5383 140th St N Check one: 0 City: Hugo Zip: 55038 County: Washington Township: Zip: County: Date(s) of activity (for raffles, indicate the date of the drawing): 4/14/19 Check each type of gambling activity that your organization will conduct: 0 Bingo = Paddlewheels = Pull -Tabs = Tipboards Raffle 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 the List of Licensees tab, or call 651-539-1900.