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RECD SEP 2 3 ZOOS <br />Minnesota L.awfui Gambling Page t of 2 9/08 <br />LG220 Application for Exempt Permit Fee is $50 for each event <br />An exempt permit may be issued to a nonprofit organization that: For Board Use Only <br />conducts lawful gambling on five or fewer days, and <br />,.4 i 1. ., xcn nnn in nrioaa Al Irinn a calendar vear. Check # _ $ <br />ORGANIZATION) INFORMATION <br />Organization name Previous gambling permit number <br />1jd ./Tine-' <br />Type of nonprofit organization, Check one, <br />Fraternal F77 Religious Veterans Other nonprofit organization <br />Mailing address City State Zip Code County <br />S27 D2 _` <br />Name <br />chief executive officer (CEO) Daytime phone number <br />/bm <br />Attach a copy of "N of the following for proof of nonprofit status. Check one. <br />Do not attach a sales tax exempt status or federal ID employer numbers as they are not proof of nonprofit status, <br />n Nonprofit Ardcles 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 />I ISI IRS Income tax exemption (601(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 />IRS - Affiliate of national, statewide, or international parent nonprofit organization (charter) <br />If your organization fails under a parent organization, attach copies of bq iLof 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 />© IRS - proof previously submitted to Gambling Control Hoard <br />If you previously submitted proof of nonprofit status from the IRS, 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 />Address (do not use PO box) City Zip Code C my <br />7,550f �r,J /v 94 O v1 a <br />Date(s) of activity (fof raffles, indicate the date of the drawing) <br />1i C Ug' <br />to tf I ad <br />Check the box or boxes that indicate the type of gambling activity your organization will conduct: <br />❑ Bingo" %Raffles ❑ Paddlewheels" Pull -Tabs" Tipboards' <br />* Gambling equipment for pull -tabs, bingo paper, tipboards, and <br />paddlewheels must be obtained from a distributor licensed by the Also complete <br />Gambling Control Board, EXCEPTION,, Bingo hard cards and bing°Page 2 of this form. <br />number selection devices may be borrowed from another organization <br />authorized to conduct bingo. <br />To find a licensed distributor, go to www.gcb,state.mn.us and click on List <br />of Licensed Distributors, or call 651-639-4076, <br />