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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 />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 INFORMATION <br />Organization Previous Gambling <br />Name: ________________________________________________________ Permit Number: ____________________________ <br />Minnesota Tax ID Federal Employer ID <br />Number, if any: ______________________________________ Number (FEIN), if any: ________________________________ <br />Mailing Address: __________________________________________________________________________________________ <br />City: ____________________________________ State: _________ Zip: __________ County: ___________________________ <br />Name of Chief Executive Officer (CEO): ________________________________________________________________________ <br />CEO Daytime Phone: _____________________ CEO Email: _____________________________________________________ <br />(permit will be emailed to this email address unless otherwise indicated below) <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 />____ 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 <br />60 Empire Drive, Suite 100 <br />St. Paul, MN 55103 <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): _________________________________________________________ <br />Physical Address (do not use P.O. box): ________________________________________________________________________ <br />Check one: <br />___ City: ______________________________________________ Zip: ___________ County: __________________________ <br />___ Township: __________________________________________ Zip: ___________ County: __________________________ <br />Date(s) of activity (for raffles, indicate the date of the drawing): ____________________________________________________ <br />Check each type of gambling activity that your organization will conduct: <br />____ Bingo ____ Paddlewheels ____ Pull-Tabs ____ Tipboards ____ Raffle <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 the List of Licensees tab, or call 651-539-1900. <br />11/17 <br />Page 1 of 2 <br />Secretary of State website, phone numbers: <br />www.sos.state.mn.us <br />651-296-2803, or toll free 1-877-551-6767 <br />Email permit to (if other than the CEO): _______________________________________________________________________