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iN�C'U JAN 2[i2 <br />Minnesota Lawful Gambling <br />LG220 AppliCatiOfl for Exempt Permit <br />An exempt permit it may be issued to a nonprofit organization that: <br />- conducts lawful gambling on five or fewer days, anr.d <br />- awards less than $50,000 in prizes during a calendar- year, <br />ORGANIZATION INFORMATION <br />Page 'I of 2 5/11 <br />Application fee <br />SED...I2t . _CAti. i_Lt ayl,_[n_eiLs:c .i._.oi _.ni_ <br />less than 30 days itore than 30 days <br />before the event before the event <br />$100 $50 <br />Check __ 537 <br />ST2i <br />Previous gambling permitnumber <br />name Isanti Chapter of Mn. Deer Hunters Association <br />X-05410 <br />Minnesota tax ID number, �... if <br />any Federal <br />edernI employer ID number, if a n y <br />41-139095843�099� <br />Type_ of nonprofit organization. Check one. <br />Fraternal ter n al Religious Veterans 1' Other nonprofit organization <br />State Zip Code <br />MN. 55008 <br />Mailing a dciresy City <br />-1st Ave. East Cambridge <br />cos <br />Narne of chief executive officer (CEO) Daytime phone number <br />ndson <br />John aria 763-689-4992 <br />Email address <br />1 <br />� Attach a copy o N E of the following for proof of n profit status. <br />_ - <br />County <br />I sa nti <br />Do not attach a sales tax exempt status or federal employer ID number as they are not proof of nonprofit status. <br />l� I <br />rigon rofit 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, Si. Paul, MN 55155 <br />Phone: 651-296-2803 <br />IRS income tax exemption [501(c)] letter in your ❑rgaiz tax'sname. <br />organization officer <br />Don't have a copy? To obtain a copy of your federal income exemptletter, have an orya <br />contact the IRS at 877-829-5500, <br />IRS <br />1 t t wide or international parent nonprofit organization (charter) <br />If your organization t organization is a nonprofit 501(c) organization with a group ruling, and <br />!o <br />Affiliate of nations .sae , <br />(xa t' <br />n falls under a parent organization, attach copies of both of the following: <br />a . IRS letter showing your par -en <br />b. the char <br />ter or letter from your parent organization recognizing your organization as a subordinate. <br />GAMBLING PREMISES INFORMATION <br />mblin event will be conducted. For raffles, list the site where the drawing will take place. <br />Name of premises where the ya g <br />Armstrong Ranch/Game Fair Address (do not use PO box) Zip Code County <br />City or township <br />Anoka <br />Anoka 55303 <br />8404-161St Ave. NW <br />Date(s) of activity (for rafflesindicate the date of the drawing) <br />August iff, 2012 <br />the type of gambling <br />the box or boxes that indicateyp activity your organization will conduct:* Pull -Tabs* <br />Bingo* Raffles Paddlewheels <br />* Gambling equipment for pull -tabs, bingo paper, tipboards, and <br />paddlewheels must be obtained from a distributor liCensed by the <br />p EXCEPTION <br />Gambling Control Board, • .: 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 ensed distributor, go to www.gcb.state.mn.us rand click <br />on List of Licensed Distributors, or call 651-639-4000 <br />Tipboards* <br />