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r �:) <br />. (3 It - <br />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 />Org ization name <br />Minnesota tax ID number, if any <br />Page 1 of 2 5/11 <br />Application fee <br />If application postmarked or received: <br />less than 30 days ore than 30 days <br />before the event before the event <br />$100 $50 <br />Check # $ <br />Previous gambling permit number <br />Federal employer ID number, if any <br />Type of nonprofit organization. Check one. <br />Mailing <br />Fraternal <br />address <br />Name f chief executive 'officer (CEO) <br />je (.t✓J <br />Religious p Veterans , <br />City <br />/9vie) kc, <br />Daytime phone number <br />5 yZ/ - 7/ 3c, <br />Other nonprofit organization <br />State Zip Code County <br />MAI > 5 30 i //AIe"- <br />Email address <br />s/O. ( x `e-et er::4ei ray --•,, Cc'q <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 />FVonprofit 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 />FFIRS - 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 />Address (do not use PO box) City or township <br />Date(s) of activity (for raffles, indicate the date of the drawing) <br />Zip Code <br />SS3�? <br />Check the box or boxes that indicate the type of gambling activity your organization will conduct: <br />Bingo* Raffles Paddlewheels* Pull -Tabs* <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 />County <br />Tipboards* <br />