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Minnesota Lawful Gambling <br />LG220a Exempt Permit Financial Reporting Form <br />12/10 <br />Issuance of an exempt permit obligates the organization to submit a financial report <br />of the event within 30 days of the gambling activity [Minn. Statute 349.166, Subd. <br />2(b)]. <br />Complete the information for the games marked with a 'Yes' as being conducted <br />below and fax or mail to the gambling Control Board. <br />Organization The Rum River Chapter of the Minn Waterfowl Assoc <br />5251 156th Ln NW <br />Ramsey, MN 55303 <br />File Number X-36665-14-005 <br />Activity Date(s) 2/27/2014 to 2/27/2014 <br />Signature f current chief executive officer <br />Mail or Fax to <br />Gambling Control Board <br />1711 W County Road B, Suite 300S <br />Roseville, MN 55113 <br />Fax: (651) 639-4032 <br />/ / / / <br />Date signed <br />Data privacy notice: The information on this form <br />and any attachments will become public information <br />when received by the Board, and will be used to <br />determine your compliance with Minnesota statutes <br />and rules governing lawful gambling activities. <br />Game(s) Conducted <br />Gross Receipts <br />Expenses <br />Net Profit <br />Value of Prizes <br />(including donations <br />and cash.) <br />Bingo No <br />Raffle Yes <br />6 1,2zoQJ <br />5j610(65 <br />35 <br />7(:),;7O, od <br />Tip Board No <br />Paddlewheel No <br />Pull Tabs No <br />Note: If tip board, paddlewheel or pull tabs are conducted the MN Licensed Distributor where product was <br />purchased is required. <br />Distributor Date of Purchase: /__ / <br />_ <br />Acknowledgment of Chief Executive Officer <br />I declare that all financial information is true, accurate, and complete. <br />'n,s /V.. AY11 rt <br />Signature f current chief executive officer <br />Mail or Fax to <br />Gambling Control Board <br />1711 W County Road B, Suite 300S <br />Roseville, MN 55113 <br />Fax: (651) 639-4032 <br />/ / / / <br />Date signed <br />Data privacy notice: The information on this form <br />and any attachments will become public information <br />when received by the Board, and will be used to <br />determine your compliance with Minnesota statutes <br />and rules governing lawful gambling activities. <br />