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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 />Organization name <br />C <br />Type of honprOfit organization. Check one, <br />Fraternal <br />Mailing address <br />Religious 1 j Veterans <br />pry Ux , l Lt <br />Name of chief executive officer (CEO) <br />Page 1 of 2 2/10 <br />Application fee for each event <br />If application pos marked or received: <br />less than 30 days more than 30 days <br />before the event before the event <br />$100 $50 <br />Check # _. $ 50, 0 (7 <br />Previous gambling permit number <br />Other nonprofit organization <br />City State <br />60 lE h (>R.\ <br />Daytime phone number <br />Zip Code County <br />,53-1-0, 7 <br />Email address <br />PF-E kso-1\ /1D.w 3%7-0I5(.9 mac,n 7 1 � Yfzso nr15r , o�,� <br />Attach a copy of ONE of the following for proof of nonprofit status. Check one. <br />Do not attach a sales tax exempt status or federal ID employer numbers as they are not 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., 180 State Office Building, St. Paul, MN 55155 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 />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 />IXIRS - proof previously submitted to Gambling Control Board <br />If you previously submitted proof of nonprofit status from the IRS, no attachment is required. <br />GAMBLING PREMISES INFORMATION <br />Name of premis <br />es es where gambling activity will be conducted (for raffles, list the site where the drawing will take place) <br />AY' � ,.1,vc. t��,, �, sue, �1 nc7KG� <br />Address do not use � O box City Zip Code County <br />cLjoL1 mist R)tE r10 <br />Date(s) of activity (for raffles, indicate the date of the drawing) <br />qv._ tort ); t3 <br />Check the box or boxes that indicate the type of gambling activity your organization will conduct: <br />l Bingo* Raffles [l Paddlewheels* Pull -Tabs* ❑ Tipboards* <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 bingo <br />number selection devices may be borrowed from another organization <br />authorized to conduct bingo. <br />To find a licensed distributor, go to www.gcb.state.mn.us and click an List <br />of Licensed Distributors, or call 651-639-4076. <br />Also complete <br />Page 2 of this form. <br />I Print Form <br />IReset Form 1 <br />