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Page 1 of 2 6/07 <br />Minnesota Lawful Gambling <br />For Board Use Only <br />LG220 Application for Exempt Permit Fee is $50 for Check #_______ <br />An exempt permit may be issued to a nonprofit organization that: <br />• conducts lawful gambling on five or fewer days, and $ <br />• awards less than $50,000 in prizes during a calendar year. each event <br />ORGANIZATION INFORMATION previous gambling permit number <br />Organization name X _ 36 3� ^ p 7 ­ 00 Z <br />Type of nonprofit organization. Check one. <br />En Fraternal [�eligious ❑ Veterans ❑ Other nonprofit organization <br />Mailing address City <br />State /Zip Code County <br />Ma <br />1✓tc) -S lZ a.�sP lV l ry 55 �►o <br />'7 /D ( 3�d Ave Daytime phone number <br />Name of chief executive officer (CEO) 7 4 3 ?� 3' y q� J <br />4 TTACH A - ZeS "' 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 />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 copy? To obtain a income tax <br />of your federalinco(me letter in <br />your organization's name. letter,, send your federal ID number and <br />Don't have a copy. <br />the date your organization initially applied for tax exempt status to: <br />IRS, P.O. Box 2508, Room 4010, Cincinnati, OH 45201 <br />_Internal Revenue Service - Affiliate of national, statewide, <br />attach c opies of boparent <br />h of the nonprofit oganization (charter) <br />If your organization falls under a parent organization, <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 />Internal Revenue Service - proof previously submitted to Gambling Control Board <br />if you previously submitted proof of nonprofit status from the Internal Revenue Service, no attachment is required. <br />GAMBLING PREMISES. INFORMATION w ill take place) <br />Nam remises where gamb� g'activity wiil be,ep�du�d (for raffles, list the site where the drawing <br />M Zip Code County <br />Address (do not use O bo) Cit �70 <br />q .1� /Gis'' 1 �►�► SS X03 <br />Date(s) of activity (for raffles, indicate th date of the drawing) �O <br />Check the box or boxes that indicate the type of gamblingactivity your organization will conduct: <br />*Bingo ' •Raffles <br />*Paddlewheels ""Pull Tabs � "Tipboards <br />® ® <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 - 407 6 . <br />—14— <br />