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MINNESOTA LAWFUL GAMBLING LG220 Application for Exempt Permit An exempt permit may be issued to a nonprofit organization that: conducts lawful gambling on five or fewer days, and awards less than $50,000 in prizes during a calendar year. If total raffle prize value for the calendar year will be $1,500 or less, contact the Licensing Specialist assigned to your county by calling 651-539-1900. ORGANIZATION INFORMATION 11/17 Page 1 of 2 Application Fee (non-refundable) Applications are processed in the order received. If the application is postmarked or received 30 days or more before the event, the application fee is $100; otherwise the fee is $150. Due to the high volume of exempt applications, payment of additional fees prior to 30 days before your event will not expedite service, nor are telephone requests for expedited service accepted. Organization r Name: T1 e:Z(J6. Svc Previous Gambling Permit Number: Minnesota Tax ID Federal Employer ID s r 6 Number, if any: G Number (FEIN), if any: -7 Mailing Address: / 7 5 O -jy'-I tcC ,ri 2 �ue o �S6! 6 C� �Sh City: �-_'�-�tt=:4� b {iJ�%State: � /"i � Zip: County: �%' Name of Chief Executive Officer (CEO): ' ��'d ` CL F 1�} ,_L�� r ) CEO Daytime Phone: �O 5 �" L'ITO ' Jq E7PCEO Email: (permit will be emailed to this email address unless otherwise indicated below) Email permit to (if other than the CEO): cc1 U (/✓1 NONPROFIT STATUS Type of Nonprofit Organization (check one): = Fraternal = Religious Veterans LET Other Nonprofit Organization Attach a conv of one of the 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): Physical Address (do not use P.O. box): Check one: ) ❑ C City: �" Township: L) - cS � Zip: 5032County: -W- 6(5 YI irl Zip: County: Date(s) of activity (for raffles, indicate the date of the drawing): 1�2 n e- q �h Check each type of gambling activity that your organization will conduct: 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.