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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 />Application fee <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# $ <br />Organization name <br />Anoka County Pheasants Forever <br />Previous gambling permit number <br />X -03898 <br />Minnesota tax ID number, if any <br />Federal employer ID number, if any <br />Type <br />— 1 <br />of nonprofit <br />Fraternal <br />organization. <br />1 Religious <br />Check <br />1 _1 <br />one. <br />Veterans L' 1 Other nonprofit organization <br />Mailing address City State Zip Code County <br />1911 Coon Rapids blvd Coon Rapids MN 55433 Anoka <br />Name of chief executive officer (CEO) Daytime phone number Email address <br />Roger Scheunemann 763757 - 7160 scheunemanncpa @hotmail.com <br />Attach a copy ofONE of the following for proof of nonprofit status. <br />Do not attach a sales tax exempt status or federal employer ID number as they are not proof of nonprofit status. <br />[lonprofit 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 <br />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 />I _JIRS - 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 />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 />Game Fair <br />Address (do not use PO box) City or township Zip Code County <br />8404 161st Ave NW ����; Ramsey 55303 Anoka <br />Date(s) of activity (for raffles, indicate the date of the drawing) <br />44 )O )O // <br />Check the box or boxes that indicate the type of gambling activity your organization will conduct: <br />Bingo* _/ Raffles Paddlewheels* Pull -Tabs* Tppboards* <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 />Minnesota Lawful Gambling <br />Page 1 of 2 5/11 <br />