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Page 1 of 2 2110 <br />hinnesora ,Lawru- vamoirny Application fee for each event <br />lication for Exempt Permit <br />G220 A Ifa ligtion ostmark dorreceived: <br />pp <br />_ <br />An exempt permit may be issued to a nonprofit organization that: less than 30 days <br />before the event more than 30 days <br />before the event <br />-conducts lawful gambling on five or fewer days, and $100 $50 <br />-awards less than $50,000 in prizes during a calendar year. <br />ORGAN1ZATlON INFORMATION Gheck~ s <br />Organization name Previous gambling permit number <br />The Church of St. Katharine ©rexel 36302-09-001 <br />Type of nonprofit organization. Check one. <br />Fraternal 0 Religious ~ Veterans ~ Other nonprofd organization <br />Mailing address City State Zip Code County <br />7101 143rd Ave NW - Suite G Ramsey MN 55303 Anoka <br />Name of chief executive officer (CEO) Daytime phone number Email address <br />Fr. Paul Jaroszeski 651-291-4415 nandrb@comcast.net <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 />^ 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, St. Paul, MN 55155 Phone: 651-296-2803 <br />IRS income tax exemption [50i(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 />If you previously submitted proof of nonprofit status from the IRS, no attachment is 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 />Ramsey Central Park <br />Address (do not use PO box) City Zip Code County <br />7925 161st Ave NW Ramsey 55303 Anoka <br />Date(s) of activity (for raffles, indicate the date of the drawing) <br />Saturday, June 12, 2010 <br />heck 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 pulhtabs, bingo paper, tipboards, and Also complete <br />paddlewheels must be obtained from a distributor licensed by the <br />Page Z of this form. <br />Gambling Control Board. IXCEPTION: Bingo hard drds and bingo <br />number selection devices may be borrowed from another organization <br />authorized to wnduct bingo. Print Form <br />To find a licensed distributor, go to www.gcb.state.mn.us and dick on Vst Reset Form <br />of Licensed Distributors, or call 651-639-4076. <br />