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MINNESOTA LAWFUL GAMBLING <br />L6220 Application for Exempt Permit <br />An exempt permit may be Issued to a nonprofit <br />organization that: <br />• conducts lawful gambling on five or hewer 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 />Organization <br />Name: White Bear Lacrosse Club_ <br />Minnesota Tax ID <br />Number, If any: <br />Mailing Address: 4440 Lake Ave <br />11/17 <br />Page 1 of 2 <br />Application Pee (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 />Previous Gambling <br />Permit Number. X-94433-19-001 <br />Federal Employer ID <br />Number (FEIN), if any: 56-2542423 <br />city: White Bear Lake state: MN — ZIP- 55110 _ — County: Washington <br />Name of Chief Executive Officer (CEO): _Stephanie Peterson <br />CEO Daytime Phone: 651 271 7955 CEO Email: j ephanie33@live.cDm _ <br />(Permit will be emailed to this email address unless otherwise indicated below) <br />Email permit to (if other than the CEO): jadon.oliila@im pacturn .Com <br />NONPROFIT STATUS <br />Type of Nonprofit Organization (check one): <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 />aA 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 foilowing : <br />1. IRS fetter showing your parent organization is a nonprofit 501(c) organization with a group ruling; and <br />2. the charter or letter From your parent o1 ganlzaUon recognizing your organization as a subordinate. <br />GAMOUNG PREMISES INFORMATION <br />Name "'F premisft where the gambling event will be conducted <br />(for raffles, list the site where the drawing will take place): Hugo American Legion_ _ <br />Physical Address (do not use P.O. box): <br />Check one: <br />0 city. _ — — — --- — — Zip:.55038 <br />[� Township: County: Washin t n <br />County: _ <br />Date(s) of activity (for raffles, indicate the date of the drawing): April 19th <br />Check each type of gambling activity that your organization will c duct: <br />MBingo F-1 paddlewheels M pull -Tabs � T+pboards <br />Raffle <br />Gambling equipment for bingo paper, bingo boards, raffle boards from a distributor licensed by the otherMinnesota Gambling Control BoardpaEXCEPTION Bingo �� raids and bingo ball obtaaine <br />devices may be borrowed from another organization authorized to conduct bingo. To find a licensed distributor., go tselection <br />o <br />www.mn.gov/gcb and click on Distribrtrs under the List of Licensees tab, or call 651-539-1900. <br />