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RFC'D f~~'~ 2 0 2010 <br />Minnesota Lawful Gambling <br />LG220 Application for Exempt Permit <br />An exempt permit mey be issued to a nonprofit organization that <br />-conducts lawful gambling on five or fewer days, and <br />-awards less than $50,000 in pr¢es during a pkndar year. <br />Page 1 of 2 9108 <br />Fee is $50 for each event <br />For Board lMe Only <br />Ctredt # s <br />ORGANIZATION INFORMATION <br />Org~~``''izafion name ,(~ Prevbus gambling permk number <br />VYa w~bl~ 1'f~'~,~n1~'.IZS x3(yg3 -Ib - ova <br />Type of nonprofit organization. Check one. <br />Fraternal ^^ Religious Veterans ~ Other nonprofit organizaton <br />Mailing address City ~ State Zip Code County <br />Name of chief exeative officer (CEO) Daytime phone number Email address <br />N~:~t~ S ~I t r 7~3 -ayl9 -Rona <br />Attach a copy of ONE of the following for proof of nonprofit status. Cheek one. <br />Do no[ attaCt a Saks tax exempt status or federal ID employer numbers as they are rxK proof of nonprofit status: <br />Nonprofit Articles of Incorporation OR a current Certlflcaa of Good Sanding. <br />Don't have a copy? This certificete must be obained each year from: <br />Secretary of Saa, Business Services Div., 780 Slate Olfice Building, St Paul, MN 55155 Phone:651-296-2803 <br />^^ IRS itteome fax exemption (501(c)] gker in your organaadon's name. <br />Don't have a copy? To obain a copy of your federal income tax exempt letter, have an ongarlaation officer <br />contact the IRS at 877295500. <br />IRS - Afiilgaof natlonal, saawide, or iMsmatlonal parent nonprofk organizatlon (charter) <br />If your organization cells under a parent organzaton, attach copies of both of the kibwirg: <br />a. IRS letter showing your parent organzaton is a nonprofit 507(c) organzation with a group mling, and <br />b. the charter or letter from your parent organzation recogmm~g your organ'vafion as a subordinate. <br />IRS -proof previowty submMad m Gambling Carrlrol Board <br />YY"----" If you Previousty sutxnilted proof of nonprofa sates from the IRS, no attachment is requirr,W. <br />GAMBLING PREMISES INFORMATION <br />Nartre of premises where gambling activity will be conduUed (for raffles, I"ist the site where the drawing will ake pace) <br />~m~ ~~ ip p~, ms ~ <br />Address (do not use T box) City ZP Cade County <br />~6 ~-toy 1(Q l s" u ~ 11 ~. ,rns 6sac~ ~`1 ms+/ <br />Date(s) of activ'ay (far raffles, indicate the date of the drawing) <br />Y- ~ -~l7tq to ~ - ~e - aaio <br />heck the tax or b~o_x/es that indicate the type of gambling activity your organzaton will conduct <br />Bingo' t~7l Raffles ~PaddlevAreels• Pull-Tabs• QTipboards• <br />* G2robli~ equipment for pttil-tabs, bingo paper, tipboattis, and Also corn <br />paddlewFleels must be obmirred from a distibrmor Iicertmd by the Plete <br />Gambling Contrd Board. IXlBrf10N: Bingo hard orris and bingo Page 2 ofthis form. <br />number selection devkt:s may be bonowed from aratfrer orgarrrratlon <br />authorized to conduct bingo. Print Form <br />To find a licensed distributor, go to www.gdt.s40e.nm.us and drdc on List Reset Form <br />of Liceftsed Distributors, or olI 651fi39.4076. <br />