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<br />Minnesota Lawful Gambling <br /> <br />LG220 Application for Exempt Permit <br /> <br />An exempt permit may be Inued to a nonproflt organization that: <br />- conducts/awful gamblrng on lIve or fewer day.. and <br />- awards leu than $50,000 in prizu during a calendar year. <br /> <br />ORGANIZATION INFORMATION <br /> <br /> <br />Check t# <br /> <br />s <br /> <br />Organization name Previous gambling permit number <br /> <br />Gt\ l.~ 14..(+1- <br />Type of nonprofit org nlzatlon. Cheek one. <br />D Fraternal Religious D Veterans 0 Other nonprofit organization <br />Mailing address City State ZIp Code County <br /> <br />'3~.5 '{2o~,-Jil lA'Ll! \3\vJ ANDOYC:A<. MtJ 5530'-1 A",.",IL- <br />Nama of chief .~ou1lve ollie., (CEO) . OayUme phone number Email address <br /> <br />N.~"-K .' Ii" L~"""'Al N '7~ 3 . ~ 2./ - C. 6 ;;> 0 """ ~ h @ ro U. ~nd",<<~. 6 J <br /> <br />Attach a copy of.QHE. of the following for proof of nonprofit status. Check 0 <br /> <br />Do not attach a sales tax exempt status or federal IO employer numbers as they are not proof of nonprofit status. <br /> <br />D <br /> <br />Nonprofit Articles of Incorpcmltlon OR a current C.rtlflcat. of Good Standing. <br />Don't have a oopy? This certlfll::ate must be obtained each year from: <br />Secretary of State. Businen Services Olv"180 State Office Building, St. Paul, MN 55155 Phone: e61-296..2803 <br /> <br />o IRS Income tu elClmptlcm [501(c)] lett" In your organization', 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 877-629-5500, <br /> <br />o <br /> <br />IRS.. Affiliate of national, statewide, or Intematlonal parent nonprofit organization (charter) <br />If your organization falls under a parent organization, attach copies of b..2!l:L.of the following: <br />a, IRS letter showing your parent organization is a nonpront 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 />D <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 /> <br />Name of premises where gambling activity will be conduoted (for raffles, list th <br />. tVlt..S A-r O~~ 1='0(2 '-. (,., o,-,p t+,vD <br />Address (do not use PO bOle) City <br />.3 3 / I AI I!" a.. NvJ <br />Oate(s) of activity (for rattle.. Indicate the date of tn. drawing) <br /> <br />T'1'7'\.HA.tl.~ '( ,50 ~ lO <br />eek the box or oxes that indicate the type of gambling activity your organization will conduct: <br />Raffles 0 PaddlewMeels' 0 Pull-Tabs" OTi!)board." <br /> <br /> <br />If-I\I 41 ~ r:-r <br />ZIp Code <br />5..5 ~o '3 <br /> <br />will take place) <br /> <br />N-r:e:-fl-. <br />County <br /> <br />o 6lngo' <br /> <br />* Gl1m ling equipment for pull-tabS, bingo paper, tlpboards, 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 organizatfon <br />authorized to conduct bingo. <br /> <br />To find a licensed distributor, go to www.gcb.state.mn.us and click on Ust <br />of Ucensed Distributors, or call 651-639-4076. <br /> <br />A so complete <br />Page 2 of this form. <br /> <br />, Print Form I <br />I Reset Form I <br />