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lninnesota Lawny taamunng <br />_G220 Application for Exempt Permit <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 />Application fee for each event <br />If application postmarked or received: <br />less than 30 days <br />before the event <br />$100 <br />more than 30 days <br />before the event <br />$50 <br />ORGANIZATION INFORMATION Check # 50:3 $ >C7 `=` <br />Organization name Previous gambling permit number <br />% / fl i i G. I'VolhyFoiv 4-CCOCv a/1) 12i r alciplfr Y —3 (AC-10 —do / <br />Type <br />of nonprofit <br />Fraternal <br />organization. <br />Check <br />Religious <br />one. <br />Veterans <br />Other nonprofit organization <br />Mailing address City State Zip Code County <br />5 / A ( e t) i2c nsey M,2) 5 53? 3 Avid . <br />Name of chief executive officer (CEO) Daytime phone number Email address <br />l 0 .5s / 'd /n - ,i LsP;4-1-- rbevkln■ktrrAvVek P yeelo <br />Attach a copy of ONE of the following for proof of nonprofit status. Check one. <br />Do not <br />ll <br />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 [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 />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 />7 L 1� /�" ra /. � ',/6e <br />Address (do not use PO box) City Zip Code County <br />9233 4/ Lid / ?c ems y 53'03 4)70 <br />Date(s) of activity (for raffles, indicate the date of the drawing) <br />E IN,G1 ty / 7 (1-G j ot/ <br />Check the box or boxes that indicate the type of gambling activity your organization will conduct: <br />Bingo* ` Raffles j Paddlewheels* ❑ Pull -Tabs* Tipboards* <br />* Gambling equipment for pull -tabs, 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 />Also complete <br />Page 2 of this form. <br />number selection devices may be borrowed from another organization <br />authorized to conduct bingo. <br />Print Form <br />To find a licensed distributor, go to www.gcb.state.mn.us and click on List <br />Licensed Distributors, or call 651 - 639 -4000. <br />Reset Form <br />of <br />Page 1 of 2 7/10 <br />