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L6220 Application for Exempt Permit A <br />Application f <br />fee <br />less than 30 days o <br />ore than 39 days <br />ORGANIZATION INFORMATION Check# $ <br />Organization name P <br />Previous gambling permit number <br />Minnesota tax ID number, If any F <br />Federal employer ID number, If any <br />Type o <br />of nonprofit organization, C <br />Check one. <br />[1 ether nonprofit organization <br />Mailing address City State Zip Code County <br />7101 143rd Ave NW Ramsey MN 55303 Anoka <br />Name of chief executive officer (CEO) Daytime phone number Email address <br />Fr. Paul Jaroszeski 763- 323 -4424 pjaroszeski a@stkdcc.org <br />Attach a copy ofONE of the following for proof of nonprofit status. <br />Don of attach a sales tax exempt status or federal employer ID number as they are not proof of nonprofit status. <br />n onprofit Articles of Incorporation Olt 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 <br />Phone: 651 - 296 -2803 <br />L UIS income tax exemption L501(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 />I .IXFIS - Affiliate of national, statewide, or international parent nonprofit organization (charter) <br />If your organization falls under a parent organization, attach copies of hash 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 />GAMBLING PREMISES INFORMATION <br />Name of premises where the gambling event will be conducted. For raffles, list the site where the drawing will take place. <br />The Fountains of Ramsey <br />Address (do not use PO box) City or township Zip Code County <br />7533 Sunwood Drive Ramsey 55303 Anoka <br />Date(s) of activity (for raffles, indicate the date of the drawing) <br />June 5, 2011 <br />Check 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 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 <br />bingo number selection devices may be borrowed from another <br />organization authorized to conduct bingo. <br />To find a licensed distributor, go to www.gcb.state.mn.us and click <br />on List Of Licensed Distributors, or call 651- 639 -4000. <br />Page 1 of 2 5/11 <br />