Laserfiche WebLink
<br />REC'U J J-l,N ~ v l-V"'~ <br /> <br />Minnesota Lawful Gambling <br /> <br />LG220 Application for Exempt Permit <br /> <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. <br /> <br />Page 1 of 2 9/08 <br />Fee is $50 for each event <br /> <br />For Board Use Only <br />Check # <br /> <br />$ <br /> <br />ORGANIZATION INFORMATION <br /> <br />Organization name Previous gambling permit number <br />C A. '~\e.,. PAyi",~e.5 i. 31413 -o~ -OO~ <br />Type of nonprofit organization. Check one. <br />[0] Fraternal I 0 I Religious [0] Veterans [OOi Other nonprofit organization <br />Mailing address City State Zip Code County <br /> <br />r ;) 1 (Ql1 t.f 0 d& ""' \'\. ~-'L Wl Y\. -.50'"42 <br />Name of chief executive officer (CEO) Daytime phone number Email address <br /> <br />... <br />MtQ.~Q...a./ H-~V\SO~ 95;;2 - fl/-Do;;6 <br />Attach a copy of ONE of the following for proof of nonprofit status. Check one. <br /> <br />Do not attach a sales tax exempt status or federal ID employer numbers as they are not proof of nonprofit status. <br /> <br />I 0 I 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, S1. Paul, MN 55155 Phone: 651-296-2803 <br /> <br />[Q]IRS Jncome tax exemption [501 (c)] letter in your organization's name. <br />D'on't have a copy? To obtain a copy of your federalincome tax exempt letter, have an organization officer <br />contact the IRS at 877-829-5500. <br /> <br />[Q] IRS - Affiliate of national, statewide, or international parent nonprofit organization (charter) <br />IT your organization falls under a parent organization, attach copies of both 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 /> <br />~ IRS - proof previously submitted to Gambling Control Board <br />J6U If you previously submitted proof of nonprofit status from the IRS, no attachment is required. <br /> <br />GAMBLING PREMISESINFORMA TION <br /> <br />Name of premises where gambling activity will be conducted (for raffles, list the site where the drawing will take place) <br /> <br />-m.B-A ~ <br />Address (do not use PO b~) <br />~YD 4. lJll ~ oLf\tU ~f\\W'GE-\{ P\ <br />Date(s) of activity (for raffles, indicate the date of the drawing) <br /> <br />to ~- }~-O <br />heck the box or boxes that indicate the type of gambling activity your organization will conduct: <br />o Bingo* ,l8f Raffles DPaddlewheels* DPull-Tabs* DTipboards* <br /> <br /> <br />...55303 <br />Zip Code <br /> <br />65303 <br /> <br />\! ct.. <br />County <br />,::'h".o{ 'A <br /> <br />* Gambling equipment for pull-tabs, bingo paper, tipboards, and <br />paddlewheels must be obtained from a distributor licensed by the <br />Gambling Control Board. EXCEPTION: Bingo hard cards and bingo <br />number selection devices may be borrowed from another organization <br />authorized to conduct bingo. <br /> <br />Also complete <br />Page 2 of this form. <br /> <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 /> <br />I Print Form I <br />I Reset Form I <br /> <br />-12- <br />