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Minnesota Lawful Gambling <br />LG220 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 />ORGANIZATION INFORMATION <br />Organization name <br />Type o nonprofit organization. Check one. <br />[LJ]Fratemal ❑ J Veteraris <br />Mailing address <br />P 0 Boe Ws) <br />Name of chief executive officer (CEO) <br />nAF__ <br />Attach a copy of m 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 - 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 mognizing your organization as a subordinate. <br />City <br />IRS Income tax exemption 601(c)1 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 - 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 />Address (do not use PO bo�C) <br />C 8 L- 104 OVE CluD <br />Date(s) of activity (for raffles, indicate the date of the drawing) <br />FL 3 —11 to R u - \ LOO' `v - <br />Check the box or boxes that Indicate the type of gambling activity your organization will conduct: <br />Other nonprofit organization <br />Daytime phone number Email address <br />t r_a9i - c1 oY� I <br />Na e of premises where gambling activity will be conduct <br />e_l <br />(for raffles, list the site where the drawing will take place) <br />9 ' , S - `'N ecyyLc57_, , 0,,,,,....c_ <br />Cit <br />0 Bingo* Raffles IJpadd1eeeIs* Pull Tabs* DTipboards i <br />* Gambling equipment for pull -tabs, bingo paper, dpboards, 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 organization <br />authorized to conduct bingo. <br />To find a licensed distributor, go to www.gcb.state.mn.us and click on List <br />of Licensed Distributors, or call 651 - 639 -4076. <br />Page 1 of 2 9/08 <br />Fee is $50 for each event <br />For Board Use Only <br />Check # 3 <br />Previous gambling permit number <br />� 31 L1%3 - ll <br />State Zip Code County <br />NOV) 6b <br />Zip Code County <br />b 1 <br />Also complete <br />Page 2 of this form. <br />1 Print Form <br />Reset Farm <br />