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CG220 ~ Minnesota Charita~'~e Gambling , ~
<br /> Application for Exemption fromFor Office Use Only
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<br /> Char[table Gambling License
<br /> Fill in the unshaded portions of this application for exemption and send it in at leas t 45 days before your gambling activin/for processing.
<br />Name and Address o, f Or~lani~a£ion
<br />Organization · bcense number
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<br /> ! Cdy .C, late
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<br /> P~;~ne ~ . Manager .,~ · . .. .~ . ~
<br />Type of A'on-pro. f[t Organization
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<br />current/previous exempt number
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<br />Years in existence &.,,,~ . Attach proof of three-years or more of existence. Number of active members _'?OO ·
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<br /> [] Fraternal [] Religious [] Veterans ,~Other non-profit
<br /> If you Checked box ~or other nonprofit, check one of the following and attach proof of nonprofit st'atus '
<br /> [] IRS designation 'J~ Incorporated with Secretary of State [] Affiliate of parent nonprofit organization (charier)
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<br />Gambling Site
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<br />NaA~e of site where a~ity wir take place
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<br /> V - t
<br />Date(s) of ~i~ _
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<br />~p~ of G~m~
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<br />Zip code
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<br />County
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<br /> "* Game ';' .. "Yes - · No ~*LTJ¥ Gros;~ receipts .. .'~ Expenses, including -,: - "~ Net profit-'-/. ?.-~=-?:-; f']' ~ '.:. ,_='.Market
<br /> -~>'"i;. ";."_:-. :. " .. Cost fPrlzes .... : .' . · -...--..-,-:.- -.- ..... . '~]:..' of Pr]zes'*~'...~;
<br />Bingo [] [~ i':'I:'''~'' ']. =--!' -".:': ~:: '.':~'-~' '"".'-'-" '":':"]::':!'~/¥'"'/?'.:~" ~' -:,.-.Li.,i-i::~:'!:.':..' ¥:i~:L:::i:..~]-~]':'
<br />Raffles ~2' [] i':. t'..-'-':.' '-" '!:: :t ' -_ .-~- . !- .']':'..-_ ,". :_'...'-"'L::!'::;'-::,:;'~'i:z';: :-'::.:i:.:;--.' -;:]
<br />Paddlewheels [] ~ .,' L;...' .' : '....: :.' ' . -.- ..','..-.: . '_..;.';.:~ .t-:..:..-':.'.: .--] 12::'-.:.'-"-:. :.-'::? :.L~':.!.?? '-
<br />Tipboards [] J~ I; :-:]' ...-i. '.: ':-, . '-. ;-.'~" · '.'-/.-: .... :':-~:': ,.¥:'"- :."/.::'=i:.]?!~:::?"/ ':':
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<br />How will profit b,e used: --
<br />. i -0. I.-=.: · :
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<br />~ '- Distributor from whom gambling equipment purchased-
<br /> [ :..-......~ '-..:::." ..i-L .---- i ~':~!':..~?'.!~-'-:'_.::
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<br />1 declare ali information submitted to the Department of Revenue
<br />is tr~;'~accurate,u~mplete
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<br />I declare ali information submitted to the Department of Revenue
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<br /> Chief executive officer's signature Date ...... Chief executive officer's signature'-'-,:. -":':' ............. '-- ;:' Date ~-':--~
<br />..Local Government Acknowledgement
<br /> I have received a copy of this application. This application will be reviewed by the Department of Revenue and will become effective 30 days
<br /> from the date of receipt by the city or county, unless the local government passes a resolution to specifically prohibit the activity. A copy of that
<br /> resolution must be received by the Department of Revenue within 30 days of the date Died in below.
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<br /> City or County Township
<br /> City county name ']'ownship name
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<br /> Si[b'Ya,,tu)e of perso),~.r~iving applic.F'['pn C""%/]) -i Signature of person rece~wng application
<br /> L'4z. :a
<br /> T~gl¢/ //,, ,, / J // Date received..--- ,, ~,,,,.I Title Date received
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<br /> ~'-~,~. L// Mail this application to:
<br /> ¥,~,o.- ~,d,.,,,.. ~o o,~.~.~ ~o Department of Revenue ~ Gaming Division
<br /> c,~-c,~,,, co~.,~ Mail Station 3315
<br /> St. Paul, MN 55146-3315
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