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C'D v5. <br />0 () 1 3 <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 />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 />12/12 Page 1 of 2 <br />Application fee (non refundable) <br />If aoolication nosted or received: <br />Tess than 30 days <br />before the event <br />$100 <br />i <br />more than 30 days <br />before the event <br />$50 <br />)( 0S- /©_ /3 c9S' <br />Organization name Previous gambling permit number <br />isanti County Chapter of the Mn. Deer Hunters Association <br />Minnesota tax ID number, If any Federal employer ID number (FEIN), if any <br />4326991 41-1390958 <br />Type of nonprofit organization. Check one. <br />Fraternal Religious <br />Mailing address <br />Name of chief executive officer [CEO] <br />Nr 2C/ -5cP <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 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 />04 it.).,1J6 t - ,SI AJ O uS- <br />, Daytime phone number <br />(7&?) (,,2c •- 499 <br />E-mall address <br />Veterans X Other nonprofit organization <br />City State Zip code County <br />.TAUT <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 contact <br />the IRS at 877-829-5500. <br />IRS - 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 />4kkt iRo,v k R/ 1G'/1 t AiLa <br />Address [do not use PO box] <br />vA�2 <br />City or township <br />Zip code <br />/l-1r,5' y "kJ SS0_S <br />Date[s] of activity. For raffles, indicate the date of the drawing. <br />4aCe(S i / / <br />Check each type of gambling activity that your organization will conduct. <br />Bingo* X Raffle Paddlewheels* Pull -tabs* <br />County <br />Tipboards* <br />*Gambling equipment for bingo paper, paddlewheels, pull -tabs, and tipboards 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 />