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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 less 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 />5/14 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 />Or.gianization name, % Previous gambling permit number <br />Minnesota tax ID number, if,any <br />Type of nonprofit organization. Check one. <br />Fraternal Religious Veterans <br />Federal employer ID number (FEIN), if any <br />Mailing address <br />Name of,chief execute gfficer [CEO] .Daytime phone number <br />/ S !,� '7b3 �S ›..')/Fs <br />NONPROFIT STATUS <br />Other nonprofit organization <br />City State Zip code County A <br />E-mailjaddress <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 />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 premises where th gambling event will be conducted. For raffles, list the site where the drawing will take place. <br />? C.Ati <br />Address [do not use PO box] City or township <br />Y.9Y 16,1s4 14,e s''' 12c fey /hN <br />Zip code CoAnty <br />s s 3.7 3PI/ (1-Q-_ <br />D te[s] off activity. For raffles,, indicate the date of the drawing. <br />� r E3. / C�l t/�' jj� / %�C� /7 G it p -e_e_ / Z c CEO <br />Check ach ty e of gambling activity that your organization will conduct. • 1 <br />Bingo* ,Raffle [total value of raffle prizes awarded for year $/i___ <br />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 />