Agenda - Council - 08/13/2013 - Laserfiche WebLink

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MINNESOTA LAWFUL GAMBLING LG220 Application for Exempt Permit An exempt permit may be issued to a nonprofit organization that: - conducts lawful gambling on five or fewer days, and - awards less than $50,000 in prizes during a calendar year. if total prize value for the year will be $1,500 or less, contact the licensing specialist assigned to your county. ORGANIZATION INFORMATION 1 Qrganization name Frevlou gambling permit number y 4.y. 1/13 Page 1 of 2 Application fee (non refundable) If application is postmarked or received 30 days or more before the event $50; otherwise $IOO. iitc its 0In L i+ &(- , 4 k Y + T Minnesota tax ID number, If any Federal employer ID number (FEIN), if any Type of nonprofit organization. Check one. --L_._ Fraternal LLReligious l ] Veterans _ Other nonprofit organization Malting address ' V-id Dr, Name of chief executive gfficer [CE ] NONPROFIT STATUS City State Zlp code County ou4.4 Lake my 5.5-3 " ...)e Daytime phone number E-mail a drgss �! (3.70) s 9'3-.7419' Atte h a copy of ONE of the following for proof of nonprofit status. z Nonprofit Articles of incorporation OR a current Certificate of Good Standing. Don't have a copy? This certificate must be obtained each year from: Secretary of State, Business Services Div., 60 Empire Drive, Suite 100, St. Paul, MN 55103 Phone: 651-296-2803 IRS income tax exemption [501(c)) letter in your organization's name. Don't have a copy? To obtain a copy of your federal income tax exempt letter, have an organization officer contact the IRS at 877-829-5500. IRS - Affiliate of national, statewide, or international parent nonprofit organization [charter) If your organization falls under a parent organization, attach copies of both of the following: a. IRS letter showing your parent organization Is a nonprofit 501(c) organization with a group ruling, and b. the charter or letter from your parent organization recognizing your organization as a subordinate. GAMBLING PREMISES INFORMATION Name of premises where the gambling event wlil be conducted. For raffles, list the site where the drawing will take place. 47 a. Ie- Fei-ie- /4r,?`7 s-71-1-0,7 q 124 P Alb ite.0/7 e /S Address [do not use PO bon_City ar township Zip code County 2)q / 7 er iU ) Ac m ceu 53e).2 /9/1 d k at Date[s] of activity. For raffles, indicate the date of the drawing, 7 Ci each type of ling activity that your organization will conduct. Bingo* lc Raffle ____Paddlewheels* 1 L Pull -tabs* El Tipboards* *Gambling equipment for bingo paper, paddlewheels, pull -tabs, and tlpboards must be obtained from a distributor licensed by the Minnesota Gambling Control Board. EXCEPTION: Bingo hard cards and bingo number selection devices may be borrowed from another organization authorized to conduct bingo. n To find a licensed distributor, go to www.gcb.state.rrin.us and click on Distributors under the WHO'S WHO? LIST OF LICENSEE'S, or call 651-639-4000.