Laserfiche WebLink
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 />If total prize value for the year will be $1,500 or less, contact <br />the licensing specialist assigned to your county. <br />ORGANIZATION INFORMATION <br />Organization name <br />iom.. &It ((V <br />Minnesota tax ID number, if at1 <br />c) <br />CvIc <br />Application fee <br />If application posted <br />less than 30 days <br />before the event <br />$100 <br />6/12 Page 1 of 2 <br />or received: <br />more than 30 days <br />before the event <br />$50 <br />Previous gambling permit number <br />Fed al employer ID number (FEIN), if any <br />2-7— 5I0S6 Z.6 <br />Type of nonprofit organization. Check one. <br />FlFraternal ri Religious Veterans Other nonprofit organization <br />Mailing address <br />i3)x �0 <br />Name of chief executive officer [CEO] <br />NONPROFIT STATUS <br />City Stat Zip code County <br />C.II R.;Vt MWe 5S 350 SIne.,buf <br />Daytime hone number <br />(-)V2. �� 4S()Z_ <br />Attach a copy of ONE of the following for 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., 60 Empire Drive, Suite 100, St. Paul, MN 55103 <br />Phone: 651-296-2803 <br />171 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 contact <br />the IRS at 877-829-5500. <br />E-mail address <br />�roCOL' (��i-dao,S rk'> : C_0ni <br />aIRS - 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 wherethe gambling event will be conducted. For raffles, list the site where the drawing will take place. <br />l 7G W\ <br />Address [do not use PO box] City or township Zip code County <br />Z401-1 t6I /\ j Itsoro'<°, 55303 Ain oko, <br />Date[s] of activity. For raffles, indicate the date of the drawing. <br />A 10 1-2- 17.I6 <br />Check eactype ofgambl'g activity thatyour organization will co <br />nduct. <br />Bingo* <br />Paddlewheels* <br />Pull -tabs* Tipboards* <br />*Gambling equipment for bingo paper, paddlewheels, pull -tabs, and tpboards must be obtained from a distributor <br />licensed by the Minnesota Gambling Control Board. EXCEPTION: Bingo hard cards and bingo number selection devices <br />may be borrowed from another organization authorized to conduct bingo. <br />To find a licensed distributor, go to www.gcb.state.mn.us and click on Distributors under <br />the WHO'S WHO? LIST OF LICENSEES, or call 651-639-4000. <br />