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<br />~Minnesota Lawful Gambling <br /> <br />LG220 Application for Exempt Permit <br /> <br />An exempt permit may be issued to a nonprofit organization Fee $50 <br />conducting lawful gambling activity on five or fewer days, and <br />awarding less than $50,000 in prizes durings a calendar year. for each event <br /> <br />Page 1 of 2 2/07 <br />For Board Use Only <br />Fee Paid <br />Check No. <br /> <br /> <br />Organization name <br /> <br /> <br />L rv1 <br />Type of nonprofit organization. Check ( ) one. <br />D Fraternal [0" Religious <br />D Veteran D Other nonprofit organization <br /> <br />Maili!,9 address J" " . City ..., r .' <br />( ~V p / Vt, ...J] n J.:J. e- <br /> <br />Name of chief executive officer (CEO) -----J 'I <br />First name G{,CI5 e. Last name 01/17501] <br /> <br />PROOF OF NONPROFIT STATUS <br /> <br />Type of proof of nonprofit status. Check (...J) one. Attach a copy (see below) <br /> <br />[2(Nonprofit Articles of Incorporation or Certificate of Good Standing - Minnesota Secretary of State's Office <br />o Internal Revenue Service <br />o Affiliate of parent nonprofit organization (charter) <br />o Proof previously submitted and on file with the Gambling Control Board <br /> <br />Sales tax exempt status or federal I D employer numbers are not proof of income tax exempt status. <br /> <br />Minnesota Secretary of State IRS Income Tax Exemption <br />Certificate of Good Standing or Under a' national organization - If your organization falls under a national <br />Nonorofit Articles of Incorporation organization, attach both of the following: <br />Attach a copy of your organization's 1. a copy of the IRS letter showing that your national organization has been <br />Certificate of Good Standing (317A) a registered nonprofit 501(c) organization and carries a group ruling, and <br />showing incorporation as a 2. a copy of the charter, or letter from your national organization, recognizing <br />nonprofit organization. your organization as a subordinate. <br /> <br /> <br />This certificate can be obtained <br />from: <br />Minnesota Secretary of State <br />Business Services Division <br />180 State Office Building <br />St. Paul, MN 55155 <br />Phone: 651.296-2803 <br /> <br /> <br />Not under a national organization - If your organization does not fall under a <br />national organization, attach a copy of the IRS income tax exemption <br />[501 (c)] letter in your organization's name. To obtain a copy of your federal <br />income tax exempt letter, send your federal 10 number and the date your <br />organization initially applied for tax exempt status to: <br />IRS <br />P.O. Box 2508 <br />R90m 4010 <br />Cincinnati, OH 45201 <br /> <br />GAMBLING PREMISES INFORMATION <br /> <br /> <br />( j)rclWt~1tfJ <br /> <br />Check the box o~~o~ that indicate the type of gambling activity your organization will be conducting: <br /> <br />~BingO U2I" Raffles 0 *Paddlewheels D *Pull-Tabs D *Tipboards <br />*Gambling equipment for pull-tabs, tipboards, paddlewheels, and bingo (bingo paper, <br />hard cards, and bingo number selection device) must be obtained from a distributor <br />licensed by the Gambling Control Board. To find a licensed distributor, g6 to <br />www.gcb.state.mn.us and click on List of Licensed Distributors. Or call 651-639-4000. <br /> <br />-24- <br />