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ORGANIZATION INFORMATION <br />Organization name Previous gambling permit number <br />Q tLC X t-- lt-k l•i09 ,J r2r4 5 c4c , 4 Cj(A9 X033)50 <br />Type <br />❑ <br />of nonprofit <br />Fraternal <br />organization. <br />❑ <br />Check <br />Religious <br />I ❑ <br />one. <br />'Veterans re(Other nonprofit organization <br />Mailing address City State Zip Code County <br />J ql r(C - M,i 4 s 3o 3 /4 Jeep( <br />ro S `I 4t,-i 1 10 i.l c gc <br />Name of chief executive officer (CEO) Daytinie phone number Email address <br />fCe6eK...r Lt.1 CIA `1Y3 E- l0-1 511 1 re 01 dm e.a.5` - <br />Attach a copy of ONE 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 />❑ <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 />❑ <br />Secretary of State, Business Services Div., 180 State Office Building, St Paul, MN 55155 Phone: 651 - 296 -2803 <br />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 />IRS - 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 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 Board <br />is <br />If you previously submitted proof of nonprofit status from the IRS, no attachment 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 />L LL s C — it( wla <br />Address (do not use PO box) City Zip Code County <br />Co (4‘. 0()J1 10 0") 1 1f5 553°3 o K i <br />Date(s) of activity (for raffles, indicate the date of the drawing) <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 <br />Gambling Control Board. EXCEPTION: Bingo hard cards and bingo <br />Also complete <br />Page 2 of this form. <br />number selection devices may be borrowed from another organization <br />authorized to conduct bingo. <br />Print Form <br />To find a licensed distributor, go to www.gcb.state.mn.us and click on List <br />Distributors, 651- 639 -4076. <br />Reset Form <br />of Licensed or call <br />Minnesota Lawful Gambling <br />LG220 Application for Exempt Permit <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 t h a n $50 00 0 in p rizes du rin g a calendar year. <br />Page 1 of 2 9/08 <br />Fee is $50 for each event <br />For Board Use Only <br />