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Minnesota Lalnrful Gambling Page 1 of 2 6/08 LG220 Application for Exempt Permit For Board Use Only An exempt permit may be issued to a nonprofit organization that: Fee IS ~rJ' 0 fOr Check# • conducts lawful gambling on five or fewer days, and • awards less than $50,000 in prizes during a calendar year. eaCll event ~ ORGANIZATION INFORMATION Organization name t ? Ch I'j'1 F ~ ~i h ~ /~ Previous gambling permit number ~- a ssn. > u ,r o a ~ 11ev~ nes a t ~ Type of nonprofit organization. Check ('~) one. ation i f t O h organ z i er nonpro t ^ Fraternal ^ Religious ^ Veterans Mailing address a I ISd~h Lstne lVIi17 City ~ar~S e State2ip Code Al 5303 County ~Io ~ Name o chief executive officer (CEO) Daytime phone number . doss rl' ~~'~ h 63~ s~6 - ~- ~yy ATTACH A COPY OF ONE OF THE FOLLOWING FOR PROOF OF NONPROFIT STATUS ~ Do not attach a sales tax- exempt status or federal ID employer numbers as they are not 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: Secretary of State, Business Services Div., 180 State Office Building, St. Paul, MN 55155 Phone: 651-296-2803 Internal Revenue Service -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. Internal Revenue Service -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. 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. Internal Revenue Service -proof previously submitted to Gambling Control Board If you previously submitted proof of nonprofit status from the Internal Revenue Service, no attachment is required. GAMBLING PREMISES INFORMATION Name of premises where gambling activit will be c nducted (for raffles, list the site where the drawing will take place) e>Is Caber' ¢ ~v ~P,~e~ Address (do not u e PO b x) ~/3 1 ~ City 12a,~se Zip Code S o County ~ Date(s) of activity (for r ffles indicate the date of the drawing) ~ /t ~ s that indicate the type of gambling activity your organization will conduct: box e Check the box or ~ / ' ^ *Bingo L(~J RafFles ^ , *Paddlewheels ^ *Pull-Tabs ^ *Tipboards * Gambling equipment for pull-tabs, bingo paper, tipboards, and paddlewheels must be obtained from a distributor licensed by the 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.gcb.state.mn.us and click on List of Licensed Distributors, or call 651-639-4076. -18- .