Laserfiche WebLink
<br />REeD MAY 2 8 2009 <br /> <br />Minnesota Lawfl1/ 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 29/08 <br />Fee is $50 for each event. <br /> <br />For Board Use Only <br /> <br />Check # <br /> <br />$ <br /> <br />ORGANIZATION INFORMATION <br /> <br /> <br />'/14") ~ Y'~ . 0/' IJ, er c' ~ ~ h F. <br />Type of nonprofit organization. Check one. _ <br />10lFraternal 101 Religious I 01 Veterans ~ Other nonprofit organization ~DI- C (, <br />Mailing address City State Zip Code <br /> <br />C B(\I(CA..~ ~ I <br />Nan of chief executive officer (CEO) Daytime phone number <br /> <br />ibk ~'Ii/l,.dL- 7&;5 -'I 2J -713oele(fJQ~1q~e <br /> <br />Attach a copy of ONE of the following for proof of nonprofit status. Check one. <br /> <br />Previous gambling permit number <br />62-08'-<50' <br /> <br /> <br />County <br /> <br /> <br />55303 <br /> <br /> <br />Email address <br /> <br />,... . trl'" <br />....~ <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 />[g] <br /> <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 /> <br />g <br /> <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 /> <br />[Q] <br /> <br />IRS - proof previously submitted to Gambling Control Board <br />If you previously submitted proof of nonprofit status from the IRS, no attachment is required. <br /> <br />GAMBLING PREMISES INFORMATION <br /> <br />Name ofPremise~ where gampling activity ~i11 be con.,ducted (for raffles, list the site where the drawing will take place) <br />(2vVl-1. ~ , c,e,"'" fI('/)~ c"'&> 1-(' c.o<./~ ~ <br />Address (do not use PO box) City Zip Code County <br />~c..5 SJ I r:;,.t:(i/U:/5 t fiLl, ;<&t~15c~ 5"5'303 'I1(.lKr <br />Date(s) of activity (for raffles, indicate the date of the drawing) <br /> <br />Z 7/01' to h z. 7/0er <br />he k the box or boxes that indicate the type of gambling activity your organization will conduct: <br />o Bingo* 00 Raffles DPaddlewheels* 0 Pull-Tabs* OTipboards* <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.Prin~ FormJ <br />I Reset Form ~ <br />