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Minnesota Lawful Gambling <br />Page 1 of 2 6/07 <br />LG220 Application for Exempt Permit <br />For Board Use Only <br />Check# <br />An exempt permit may be issued to.a nonprofit organization that: _ Fee is $50 for <br />• conducts lawful gambling on five or fewer days, and <br />event <br />$ <br />• awards less than $50,000 in prizes during a calendar year. eaCh <br />ORGANIZATION INFORMATION <br />Organization name <br />Previous gambling permit number <br />i (A- J <br />Type of nonprofit organization. Check M one. <br />❑ Fraternal ❑ Religious ❑ Veterans [ Other nonprofit organization <br />Mailing address <br />City <br />State/Zip Code <br />County <br />e► .57'iA <br />eti5 <br />VA -i s O <br />0:fC <br />Name of chief exe utive officer (CEO) <br />Daytime phone number <br />1Q06ev,' Lipi4hex—i <br />1 (,3 4)151-1 I <br />ATTACH A COPY OF ONE OF THE FOLLOWING FOR PROOF OF NONPROFIT STATUS <br />Do not attach a sales tax exempt status or federal ID employer numbers as they are not proof of nonprofit status. <br />Nonprofit Articles of Incorporation OR a current Certificate of Good Standing. <br />_ <br />Don't have a copy? This certificate must be obtained each year from: <br />Secretary of State, Business Services Div., 180 State Office Building, St. Paul, MN 55155 Phone: 651-296-2803 <br />_Internal Revenue Service - 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, send your federal ID number and <br />the date your organization initially applied for tax exempt status to: <br />IRS, P.O. Box 2508, Room 4010, Cincinnati, OH 45201 <br />Revenue Service -Affiliate of national, statewide, or international parent nonprofit organization (charter) <br />_Internal <br />If your organization falls under a parent organization, attach copies of both of the following: <br />a. IRS letter showing your parent organization is a registered nonprofit 501(c) organization with a group ruling <br />b. the charter or letter from your parent organization recognizing your organization as a subordinate. <br />Revenue Service -proof previously submitted to Gambling Control Board <br />_Internal <br />If you previously submitted proof of nonprofit status from the Internal Revenue Service, no attachment is required. <br />GAMBLING PREMISES INFORMATION <br />Name of premises where gambling activity will be conducted (for raffles, list the site where the drawing will take place) <br />Tlil <br />Address (do not use PO box) <br />4 us G <br />City <br />,' � <br />Zip Code <br />�3c3 . <br />County <br />Date(s) of activity (for raff es, indicate the date of the drawing) <br />tKk ZZs-QG <br />Check the box or boxes that indicate the type of gambling activity your organization will conduct: <br />❑ *Bingo X Raffles ❑ *Paddlewheels ❑ "Pull -Tabs ❑ `Tipboards <br />* Gambling equipment for pull -tabs, tipboards, paddlewheels, and bingo (bingo paper, <br />hard cards, and bingo number selection device) must be obtained from a distributor <br />licensed by the Gambling Control Board. To find a licensed distributor, go to <br />www.gcb.state.mn.us and click on List of Licensed Distributors, or call 651-639-4076. <br />-24- <br />