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Minnesota Lawful Gambling <br />Page 1 of 2 6/07 <br />LG220Application for Exempt Permit For Board Use only ° <br />An exempt permit may be issued to a nonprofit organization that: Fee 1$ $50~fOr Check# <br />• conducts lawful gambling on five or fewer days, and <br />a <br />d <br />ri <br />l <br />d <br />d <br />l <br />000 i <br />i <br />h <br />h event ~ <br />• aw <br />r <br />ng a ca <br />en <br />s <br />ess. t <br />an $50, <br />n pr <br />zes <br />u <br />ar year. eac <br />ORGANIZATION INFORMATION .. <br />Organization name Previous gambling permit number <br />CTcn'A`R. D i ~ ~ h1G,-t~LS cad 1 V i ~ ~~ ~ ' ~ - C7~ <br />Type of .nonprofit organization. Check (~) one. ~ J <br />^ Fraternal ^ Religious ^ Veterans Other nonprofit organization <br />Mailing address City State2ip Code County <br />~ $O ~. V ~ -~s ~ ~~ w~ £..~ =U~ r 1M IN .~~~ S ~ v~cr, <br />Name of chief executive officer (CEO) <br />~ Daytime phone number <br />~ <br />~a-,.~~e~ <br />~..~~kerJ 3~~~)-~ <br />~~ <br />ATTACH 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 />Sacretary of State, Business Services Div., 180 State Office Building, St Paul, MN 55155 Phone: 65'I-296-2803 <br />`~ <br />/Internal Revenue Service -IRS income tax exemption [501(c)] letter in your organ"~zation's name. <br />DonY have a copy? To obtain a copy of your federal income tax exempt letter, send your federal ID number and <br />the date your organization initially applied for tax exempt status to: <br />IRS, P.O. Box 2508, Room 4010, Cincinnati, OH 45201 <br /> <br />Intemal Revenue Service -Affiliate of national, statewide, or international parent nonprofit organization (charter) <br />if your organization falls under a parent organization, attach copies of both of the following: <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 />Intemal Revenue Service -proof previously submitted to Gambling Control Soard <br />If you previously submitted proof of nonprofit status from the Intemal Revenue Service, no attachment is required. <br />GAMBLING PREMISES INFORMATION <br />Name of premises where gambling activ""ity will be conducted (for raffles, list the site where the drawing will take place) <br />-e~hw~a~ r~s a ~ ~~m St <br />Ad ess (do not use PO box) <br />~ 3~ S~ N i,/arcli l~r; v ., C' <br />~a t-,r,. Y t Zip Code <br />j ~ 3 ~ 3 ounty. <br />~ lv ~ k ~ <br />of activity (for raffles, indicate the date of the drawing) <br />Date <br />( <br />s <br />) <br />q <br />~ <br />y <br />~ <br />f' ~>cV~ ~ ~~3Z~G <br /> <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 egwipment 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 distributer, go m <br />www.gcb.state.mn.us and dick on List of Licensed Distributors, or call 651-6391F076. <br />-24- <br />