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<br />Minnesota Lawful Gambling <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 day&, and <br />awarding less than $50,000 in prizes durings a calendar year. fo r ea c h eve n t <br /> <br />Page 1 of 2 2/07 <br />For Board Use Only <br />Fee Paid <br />Check No, <br /> <br /> <br />ORGANIZATION INFORMATION. <br /> <br />~ ) ./ f' ( Previous lawfl,l~~bling exemption number <br />o+' ~/...... .f ~t:iIl,Afi'M ,!.4yJa ...v ~ ~ <br />Type of nonprofit organization. Check ( ) one, <br />o Fraternal ~ Religious <br />o Veteran 0 Other nonprofit organization <br />Mailing addreSSA 1/ \ <' G City r-:J <br />'110 (I ~ v< Nw jc,;;k /<q ~ j(! <br />Name of chief executive officer (CEO) <br />First name 4' <br />r. <br /> <br /> <br /> <br /> <br />Type of proof of nonprofit status. Check (..J) one. Attach a copy (see below) <br /> <br />,. D Nonprofit Articles of Incorporation or Certificate of Good Standing - Minnesota Secretary of State's Office <br />:m 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 10 employer numbers are not proof of income tax exempt status. <br /> <br />Minnesota Secretary of State IRS Income Tax Exemption <br />Certificate of Good Standina or Under a national organization - If your organization falls under a national <br />Nonorofit Articles of Incorooration organization, attach both of the following: <br />Attach a copy of your organization's 1. a copy of the I RS 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 />This certificate can be obtained <br />from: <br />Minnesota Secretary of State <br />Business Services Division <br />180 State Office Building <br />Sl Paul, MN 55155 <br />Phone: 651-296-2803 <br /> <br /> <br />Not under a nationalorQanization - 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 federallD number and the date your <br />organization initially applied for tax exempt status to: <br />IRS <br />P.O. Box 2508 <br />Room 4010 <br />Cincinnati, OH 45201 <br /> <br /> <br />. . ..'." , <br />GAMBLING,:,PREMISES'INFORMATION' <br /> <br /> <br /> <br />Check the box or boxes that indicate the type of gambling activity your organization will be conducting: <br /> <br />o *Singo )Q Raffles 0 *Paddlewheels 0 *Pull-Tabs 0 *Tipboards <br /> <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, go to <br />www.gcb.state.mn.us and click on List of Licensed Distributors, Or call 651-639-4000. <br /> <br />-28- <br />