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<br />H\:.C'U ..J po. 1\\ v u '- V I v <br /> <br /> <br />Minnesota Lawful Gambling <br /> <br />LG220 Application for Exempt Permit <br /> <br />An exempt permit may be issued to . nonprofit organization that: <br />. conducts lawful gambling on flve or fewer days, and <br />. awards less than $50,000 In priZes during a calendar year. <br /> <br />ORGANIZATION INFORMATION <br /> <br /> <br />~' · h C~ ? l.1 <br />Type of nonprofit org.nllltlo"_ Check one. . <br />o Fraternal 0 Religious 0 Veterans C2S Other nonprofit organization <br />Malllng address. City State Zip Code <br />1(;~ I 15?,-f17 LCfMe NrU 1~rr!5&1. i'v1iJ 'f5?oJ <br />Name of chief executive officer (CEO) Daytime phone number <br />I2.CJ~S H. 1I~/'1 1~3... 1.f~7- GS,.q.. ru.lt'wr'veV"'wtl4/a(Jy(i/&r',(,~j:' <br /> <br />Attach a copy of.QHE of the following for proof of nonprofit status. Check one. <br /> <br /> <br />Pa e 1 of2 7/09 <br />Application fee <br />Ii n a r r Iv ' <br />less than 30 days more than 30 days <br />before the event before the event <br />$100 $50 <br /> <br />Cheek # ~O i .., s ~ C' <br /> <br />Previous gambling permit number <br />, X-3'''6,-o~",00 <br /> <br />County <br /> <br /> <br />Emall address <br /> <br />00 not attach a sales tax exempt status or federal 10 employer numbers as they are not proof of nonprofit status. <br /> <br />O Nonprofit Artlcl.. of Incorporation OR a. current Certlflcate of Good Standing. <br />Don't have a copy? Tnia certl1lcate must be obtained each year from: <br />,Secretary of State, Business Services Olv., 1 SO State Office Building, St. Paul, MN 55155 Phone: 651.296.2803 <br /> <br /> <br />o IRS Incom. tax exemption [501(c)] letter in your organization'. name. <br />Don't h.ve a copy? To obtain. copy of your federal Income tax exempt letter, have an organization officer <br />eontact the IRS at 877-829-5500. <br /> <br />o <br /> <br />IRS. Afflllat. of nltlonal, .tatewld., or International parent nonprofit organization (charter) <br />If your organization falls under a parent organization, attach copies o1l:lm.tl.of the following: <br />I, 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 /> <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 of premises where gambling activity will be conducted (for raffles, list the site where the drawing will take place) <br />..-rl;~ Lt'rt /~S af' ,A"t~1 fov ~ <br />Address (do not use PO bo,X) , Ci Zip Code ~untY/, <br />q :53 J A) P 1J1..o.. Dflve.. )JuJ L':WI'", S e . 'S 53 () ;\j)WK a <br />Date(s) of activity (for raffles, Indicate the date of the drawing) <br />Fe6VY.La JgftJ J c9.L)/O <br />hIck the box or boxes that Indicate the type of gambling activity your organization will conduct: <br />o Bingo. ~atrl.a 0 Plddlewheets. 0 Pull.. Tabs. o Tlpboards. <br /> <br />'" Gambling equipment for pull-tabs, bingo paper, tlp~rdl, and <br />pllddlewheels must be obtained from a distributor licensed by the <br />Gambling Control Board. exC:EFrION: Bingo hard cards Ind bingo <br />number selection devices may be borrowed from another organization <br />authortzed to conduct bingo. <br /> <br />Also cemplete <br />Page 2 ofthls form. <br /> <br />To find a licensed distributor, go to www.gc:b.state.mn.us and click on Ust <br />of Ucensed Distributors, or call 651-639-4076. <br /> <br />I PrInt Form ,I <br />I Reset Form I <br />