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MINNESOTA LAWFUL GAMBLING LG220 Application for Exempt Permit 8/14 Page 1 of 2 An exempt permit may be issued to a nonprofit organization that: Application fee (nonrefundable) • conducts lawful gambling on five or fewer days, and . awards less than $50,000 in prizes during a calendar year. If the application is postmarked or received 30 days or more before the event, the application If total prize value for the year will be $1,500 or less, contact the Licensing fee is $50; otherwise the fee is $100. Specialist assigned to your county. Organization Information Organization Name: Previous Gambling Permit Number: ' a _037-01 - S� nnesota Tax ID Number4 , if any: federal Employer ID Number (FEIN), if any: -iY2giy Type of Nonprofit Organization (check one): Fraternal Religious =Veterans ©Other Nonprofit Organization Mailing Address: City: State and Zip: County: ' or 09 T t10�<t-..0 l n.N)02 - Nam of Chief Executive Officer (CEO): Daytime Phone: Email: (r h W4 Nonprofit Status 12@ Cwt Attach a copy of ONE of the following for proof of nonprofit status: ® Nonprofit Articles of Incorporation OR a current Certificate of Good Standing. Don't have a copy? This certificate must be obtained each year from: Minnesota Secretary of State Business Services Division 60 Empire Drive, Suite 100 St. Paul, MN 55103 Phone: 651-296-2803 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 at 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: a. an IRS letter showing your parent organization is a nonprofit 501(c) organization with a group ruling, and b. 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): r5 v3 rf 11 r6w Address (do not use PO box): City or Township: Zip Code: County: lU S Date(s) of activity (for raffles, indicate the date of the drawing): Check each type o gambling activity tfiat your organization will conduct: Bingo* =Paddlewheels* Pull -Tabs* =Tipboards* Raffle (total value of raffle prizes awarded for the year: $_ *Gambling equipment for bingo paper, paddlewheels, pull -tabs, and tipboards must be obtained from a distributor licensed by the Minnesota Gambling Control Board. EXCEPTION: Bingo hard cards and bingo number 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 USTOFUCENSEES, or call 651-539-1900.