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MINN F1SOTA LAWFUL GAMBLING <br />LG220 Application for Exempt Permit <br />An exempt permit may be issued to a nonprofit organization that: <br />- c)nducts lawful gambling on five or fewer days, and <br />- a/cards less than $50,000 in prizes during a calendar year. <br />If total pize value for the year will be $1,500 or less, contact the licensing <br />specialist assigned to your county. <br />ORGANIZATION INFORMATION <br />pcsoniz , ion name <br />WQ To c4(51c_t, <br />Minnesota tax ID number, if any Federal employer ID number (FEIN), if any <br />1/13 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 $1.00. <br />I 37.55?73 <br />Type of nonprofit organization. Check one. <br />Fraternal <br />,w> <br />Religious Veterans <br />Mai arress <br />Nisatune of 'Fhief executive officer CEO] <br />Or) 00 <br />NONPROFIT STATUS <br />Attac <br />City <br />PI ‘S <br />Previous gambling permit number <br />Other nonprofit organization <br />State <br />rno <br />Daytime phone number <br />'ft t9 <br />copy of ONE of the following for proof of nonprofit status. <br />Zi code County <br />CALI 11Y-1UPIC\ <br />E-mail address <br />6 30,-1p <br />N+nprofit Articles of Incorporation OR a current Certificate of Good Standing. <br />Oon't have a copy? This certificate must he obtained each year from: <br />ecretary of State, Business Services Div., 60 Empire Drive, Suite 100, St. Paul, MN 55103 <br />Flhone: 651-296-2803 <br />IF 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 />t )e IRS at 877-829-5500. <br />IRS - Affiliate of national, statewide, or international parent nonprofit organization [charter] <br />, your organization falls under a parent organization, attach copies of both of the following: <br />al. 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 />I <br />GAMB ING PREMISES INFORMATION <br />Nat e of remises where the gambling event will be conducted. For raffles, list the site where the dray/log will take place, <br />4 . <br />Address [1.10 not use PO box City or township Zip codeo <br />3S :: County <br />Date[s] ol activity. For raffles, indicate the date of the drawing. <br />1.1.1,4iSZI7 12Ci (I ()). 41-4-41--16 /5/ i / 7 <br />Check Oat% type of ganibling activity that your org&rflization will conduct, <br />Birigol' \a/ Raffle Paddlewheels* Poll -tabs"' <br />i <br />*GaMbling equipment for bingo paper, paddlewheels, pull -tabs, and tiphoards roust be obtained from a distributor <br />lice4ed by the Minnesota Gambling Control Board. EXCEPTION: Bingo hard cards and bingo number selection devices <br />may be borrowed from another organization authorized to conduc:t bingo, <br />Tipboards*" <br />To fired a licensed distributor, go to www.gcb.stateann.us and click on Distributors <br />Linde the WHO'S WHO? LIST OF LICENSEES, or call 651-539-1900. <br />