Laserfiche WebLink
763-526-5896 03;43:41 p.m. 05-07-2014 2/11 <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 Tess than $50,000 in prizes during a calendar year. <br />If total prize value for the year will be $1,500 or less, contact the licensing <br />specialist assigned to your county. <br />ORGANIZATION INFORMATION <br />Organization name e <br />1 A.11ef <br />3/14 Page 1 of 2 <br />Application fee (non refundable) <br />If application is postmarked or received 30 days or <br />more before the event$50; otherwise $100. <br />Previous gambling permit number <br />Minnesota tax ID umber if any F eral employer ID number (FEIN), if any <br />Type of nonprofit organization. Check one. <br />Fraternal Religious Veterans Other nonprofit organization <br />Mailing a ress City State <br />(0/ h)lk Aiu a' Rd fr;o(kv rnt1 <br />Name of of exec 'e officer [CEO) me Se ylle-r( <br />Pla dJct11-e/3i <br />NONPROFIT STATUS <br />Zip code County <br />SS-13 2 Ho Dkc,_. <br />E-mail address <br />k'rla .b lam beri @ ycht a. for <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 />X 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 pre es whereAle gambling event will be conducted. For raffles, list the site where the drawing will take place. <br />Koff) Kivtc khllr od/¢ (Lob <br />Address [do not use PO bo City or to nship Zip code <br />%` ar►cf:r Iva( rr�-cv Ml� S <br />• Coun y <br />1 l0 (69 c `� o? 'tp <br />Date[s] of activity. For raffles, indicate the date of the drawing. <br />Check each tylfe of gambling activity that your organization will conduct. <br />Bingo* Raffle [total value of 'raffle prizes awarded for year , 00 0] Paddlewheels* _Pull -tabs* 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 <br />under the WHO'S WHO? LIST OF LICENSEES, or call 651-539-1900. <br />