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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 $50 for <br />• conducts lawful gambling on five or fewer days, and <br />• awards less than S50,000 in prizes during a calendar year each event <br />$ <br />ORGANIZATION INFORMATION- <br />Organization name <br />A 4 0 )<, •, C ulsel ,h4.1 ig, ,,/,. Po- ,e t...er <br />Previous gambling permit number <br />Type of nonprofit organization. Check ('/) one. <br />• Fraternal El Religious 0 Veterans Other nonprofit organization <br />Mailing address A <br />I ?// "C.e.e.-1 140; <br />City <br />State/Zip Code <br />..c.ry33 <br />County <br />Apokl <br />Name of executive officer (CEO) <br />.-5 c..- -4,1 <br />Daytime phone number <br />)6.3 >x,•.--"P/Co <br />ATTACH x COPY Of ONE: gp.:TH , FOLLOVVINa , ' P OF:OF:NONPROFIT STATOS:. <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 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, have an organization officer <br />contact the IRS at 877-829-5500. <br />_ Internal Revenue Service - Affiliate of national, statewide, or international parent nonprofit organization (charter) <br />If your organization falls under a parent organization, attach copies of goft of the following: <br />a. IRS letter showing your parent organization is a nonprofit 501(c) organization with a group ruling, and <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 <br />Name of premi where gambling activity will be conducted (for raffles, list the site where the drawing will take place) <br />Address (do not use PO box) <br />c y ' t/ t 9 Y I 61 ,r i- A r <br />City ^ <br />i 4 - 1 A, td <br />Zip Code <br />Criunty <br />Date(s) of activity (for raffles, indicate the date of the drawing) <br />4 •-■ J4 r> .....o• <br />Check the box or boxes that indicate the type of gambling activity your organization will conduct: <br />ED "Bingo X Raffles 0 *Paddlewheels El "Pull-Tabs E "Tipboards <br />* Gambling equipment for pull-tabs, bingo paper, tipboards, and paddlewheels must <br />be obtained from a distributor licensed by the Gambling Control Board, <br />EXCEPTION: Bingo hard cards and bingo number selection devices may be borrowed <br />from another organization authorized to conduct bingo. <br />To find a licensed distributor, go to www.gcb.state.mn.us and click on List of Licensed <br />Distributors, or call 651-639-4076. <br />wful Gamblin <br />Page 1 of 2 6/08 <br />