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no -29-2015 20:43 FROM:DAVIS SALES & SERVIC 507-642-3562 <br />MTNNESO'dtA LAWFUL GAMBLING <br />c LC220 Annlicatlon for Exempt Permit <br />TO:17634339898 P.1'2 <br />8/14 <br />Page 1 of 2 <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 Tess, contact the Licensing <br />Specialist assigned to your county. - <br />Application fee (nonrefundable) <br />If the application Is postmarked or received <br />30 days or more beforo the event, the application <br />fee Is $50; otherwise the fee Is $100, <br />Organization information <br />Organization Name: Previous Gambling Permit Number: <br />Commerce & Visitors Bureau <br />Madelia Area Chamber of <br />Minnesota Tax ID Number, If any; Kederal employer ID Number (FLIN), IF any: <br />-1467797 <br />._5:121§13____________.----41 <br />Typo of Nonprofit Organization (check one): <br />Fraternal <br />Religious []veterans <br />ti <br />Other Nonprofit Organization <br />Ma <br />ling Address; <br />City; State and Zip; County; <br />Madelia MN 56062 Watonwan <br />PO BOX 171 <br />Name of Chief Executive Officer (CEO): Daytime Phone: email; <br />Karla Grey 507-64243822 <br />� <br />Nonprofit Status <br />Attach a copy of ONE of the following for proof of nonprofit statue; <br />I1 <br />Nonprofit Articles of Incorporation OR a current Certificate of Good Standing. <br />be obtained each year from: <br />Don't have a copy7 This certificate must <br />Minnesota Secretary of State <br />Business Services Division <br />60 Empire Drive, Suite 100 <br />St. Paul, MN 55103 <br />Phone: 651-296-2803 <br />IRS Income tax exemption (501(c)) Tetter In your organization's name. <br />Income tax letter, have an organization officer contact <br />Don't have a copy? To obtain a copy of your federal exempt <br />the IRS at 877-829-5500_ <br />YRS - Affiliate of national, statewide, or International parent nonprofit organization (charter). <br />of both of the following; <br />If your organization falls undor a parent organization, attach copses <br />a, an 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 the gambling event will be conducted (for raffles, Ilst the site where the drawing will take place); <br />Game Fair _ <br />Address (do not use PO box); City or Township: Zip Code: County: <br />;,14 . 1 -g : ► A 1100 13 <br />Date(s) of activity (for raffles, Indicate the date of the drawing); <br />Drawing will be held on August 16, 2015 <br />Check each type of gambling activity that your organization will conduct: <br />Bingo* Li Paddlewheels* <br />Pull -Tabs* [JTipboards* <br />jRaffle (total value of raffle prizes awarded for the year: $ 6,800,00 ) <br />&Gambling <br />licensed <br />be <br />To <br />or <br />equipment for bingo paper, paddlewheels, pull -tabs, and tipboards must be obtained from a distributor <br />by the Minnesota Gambling Control Board. EXCEPTION; Bingo hard cards and bingo number selection devices may <br />borrowed from another organization authorized to conduct bingo. <br />find a licensed distributor, go to www.mn.gov/gcb and click on Distributors under the LIST OF LICENSEES, <br />call 651-539-1900. <br />