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CG220 Minnesota Charitable Gambling <br /> Application for Exemption from For Office Use Only <br /> Charitable Gambling License <br /> <br /> Fil; in the unshaded portion.~ of this apphcation for exemption and send it in at least 45 days before your gambling act/vi~.' for process/n~c. <br />Name and Address o.f Or.oanization <br /> <br />t';7.'"'] : ~' ~ ' : ' '. ' : ' ' : .... '-'"~: .... : i ; <br /> <br />Street C~b, State Z~p cooe i Counly <br /> ~ - '. .,. · ,c- . '' , ,. ~ . . . ~,,. --- J <br /> <br />Chief executive officer Phone Manager Phone <br /> <br />Type of Non-pro. fit Organization <br /> <br />Years in exislence ~. Attach proof of three-years or more of existence. Number el active members ;. ; <br /> <br /> ~ FraternaJ [] Religious f-q Velerans ~.Other non-profit <br /> <br /> If you checked box for other nonprofit, check one of lhe following and attach proof of nonprofit status <br /> ~ IRS designation [] Incorporated with Secretary of State ~ Affiliate.of parent nonprofit organization (charter) <br /> <br />Gambling Site <br />Name of site where activity will take place <br /> <br />Street City State Zip code <br /> <br />Date(s) of activity <br /> <br />Types of Games <br /> <br />County <br /> <br />Game Yes No <br /> <br /> Financial Report <br />/ .' 'Gr&ss recei~s I Expenses, including Net profit <br />· * Cost of Prizes , <br /> <br />Bingo [] [] <br />Raffles ,~.~ [] <br /> <br />Paddlewheels [] ~ I <br /> <br />Marke! Value <br />of Prizes <br /> <br />Tipboards [] [] <br />Pull-tabs [] [] I <br />Hqw will profit be used: Distributor from whom gambling equipment purchased <br /> ...... ;.,~ ~.: ::: .'~ t ~: .' .~';,: :. ;.:. '...~_:'::' *~- :' -: ...- ;: <br /> <br /> Distributor's ticense number <br /> .;';L:.~L--' ,T_: Z:=: .... ' ,:', <br /> <br />I declare all information submitted to the Department of Revenue I declare all information submitted to the Department of Revenue <br />is true, accurate, and complete .. is true, accurate, and complete <br /> :' ..~ / <br /> <br />Chief executive officer's si?ature · ' Date Chief executive officees si~anature 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 loc. at 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 filled in below. <br /> <br />City or County Township <br />C~ty or county name <br /> <br />Signature of person reoelvlng application <br /> <br />Title <br /> <br />Date received <br /> <br />township name <br /> <br />Signature of person recewJng application <br /> <br />Title Date received <br /> <br /> Mail this application to: <br />Department of Revenue ~ Gaming Division <br />Mail Station 3315 <br /> St. Paul, MN 55146-3315 <br /> <br /> <br />