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<br />REC'D JUN 2 2 2009
<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 />OB9t;~'1~l'(Q:NiINffiqR.MJ\TIQN@',;;,,~ ", .,
<br />
<br />Organization name
<br />ANOKA COUNTY PHEASANTS FOREVER
<br />
<br />Page 1 of 2 9/08
<br />Fee is $50 for each event
<br />
<br />For Board Use Only
<br />
<br />Check #
<br />
<br />j
<br />
<br />
<br />Previous gambling permit number
<br />X-08398
<br />
<br />Type of nonprofit organization. Check one.
<br />II] Fraternal I DI Religious II]Veterans ~ Other nonprofit organization
<br />Mailing address City State Zip Code County
<br />1911 COON RAPIDS BLVD COON RAPIDS MN 55433 Anoka
<br />
<br />Name of chief executive officer (CEO)
<br />ROGER SCHEUNEMANN
<br />
<br />Daytime phone number
<br />7637577160
<br />
<br />Email address
<br />scheunemanncpa@hotmail.com
<br />
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<br />A tta c Ii ad;py ;6f 'ON Eofthe fOlloWin9'fgrJlm)pf"Pfr1PQprpfitstatus..C:heckpne.
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<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 />
<br />[Q]
<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 />Ii your organizalion falls under a parent organization, attach copies of both of the following:
<br />
<br />a. IRS letter showing your parent organization is a nonprofit 501(c) organization with a group ruling, and
<br />b, the cllarLr or letter from your parent organization recognizing your organization as a subordinate.
<br />
<br />~
<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 />
<br />Na'me of premiseS' Where gam6Iin!;l'activlfY\NiWb&.c6Milittedt(fotr~ffles;'lisf"thesltewhere the draIMhgWiII take place) ". '
<br />G,!l..ME FAIR
<br />
<br />
<br />Address IJo not use 1'0 box)
<br />8404 161ST AVE NW
<br />
<br />City
<br />
<br />Zip Code
<br />55303
<br />
<br />County
<br />Anoka
<br />
<br />RAMSEY
<br />
<br />Date(s) c: "c;tivity U:,r fOlfflcs, indicate the date of the drawing)
<br />
<br />08-1 G-2:)09
<br />
<br />to 08-13-2(<09
<br />
<br />heck li ie box or bCAes tllat indicate the type of gambling activity your organization will conduct:
<br />D l3ingo* [~Raffles DPaddlewheels* DPull-Tabs* o Tipboards*
<br />
<br />* C'JrnL",'] ('r;~!:pm2nt r:;, ;,ulHabs, 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 />,JuU10r;'~r: to conduct bingo.
<br />
<br />Also complete
<br />Page 2 of this form.
<br />
<br />1-
<br />
<br />To finn 3 I'rl'nsed distributor, go to www.gcb.state.mn.us and click on List
<br />cr Licf:I";ed Distributors, or call 651-639-4076.
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