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1 @ z <br />MINNESOTA LAWFUL GAMBLING <br />220 Application for Exempt Permit <br />12/12 Page 1 of 2 <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 />Application fee (non refundable) <br />If application posted 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 <br />Organization name I (� , l Previous gamb ing permit number /_ <br />Yki Ititvi-LSOliA, 061,��'i,3'NOI P, 1`k;` /Crlt"" r�.�1im RIVe �IiP0'ip're,vr — 3 A. 6✓ <br />Minnesota tax ID number, if any Federal employer ID number (FEIN), if any <br />Type of nonprofit organization. Check one. <br />Fraternal Religious Veterans X Other nonprofit <br />organization <br />Mailing address City r State Zip code County <br />,`�/ /51'/i 1_,-me 4/a/ l?a/ se y r. v 5-5 O3 4/a0 /(A,_ <br />Name of chief ex cutive officer [CEO] Daytime phone number E-mail address <br />/ ea. s /0 - kedr i 2 3_ 7 __ es - rvm rr vtrrwadyeil , f0 <br />NONPROFIT STATUS <br />Attach a copy of ONE of the following for proof of nonprofit status. <br />Nonprofit Articles of Incorporation OR a current Certificate of <br />Good Standing. <br />100, St. Paul, MN 55103 <br />name. <br />letter, have an organization officer contact <br />nonprofit organization [charter] <br />of both of the following: <br />organization with a group ruling, and <br />your organization as a subordinate. <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 <br />Phone: 651-296-2803 <br />IRS income tax exemption [501(c)] letter in your organization's <br />Don't have a copy? To obtain a copy of your federal income tax exempt <br />the IRS at 877-829-5500. <br />IRS - Affiliate of national, statewide, or international parent <br />If your organization falls under a parent organization, attach copies <br />a. IRS letter showing your parent organization is a nonprofit 501(c) <br />b. the charter or letter from your parent organization recognizing <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 />"7-7/ e 2. -14//' 4 ,11 r-/-71 FF?v/ <br />Address [do not use PO box] City or to r nship Zip code County <br />ra r <br />Date[s] of activity. For raffles, indicate the date of the drawing. <br />e''6 trfrfe 3/!n, /% / 51> / 6r <br />Check each type of ambling activity that your organization will conduct. <br />Bingo* Raffle Paddlewheels* Pull -tabs* Tipboards* <br />from a distributor <br />number selection devices <br />*Gambling equipment for bingo paper, paddlewheels, pull -tabs, and tipboards must be obtained <br />licensed by the Minnesota Gambling Control Board. EXCEPTION: Bingo hard cards and bingo <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 />