Agenda - Council - 06/26/2007 - Laserfiche WebLink

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'I_ Minnesota Lawful Gambling Page 1 of 2 4107 LG220Application for Exempt Per mit For Board Use Only Fee Paid An exempt permit may be issued to a nonprofit organization Fee $50 conducting lawful gambling activity on five orfewer days, and awarding less than $50,000 in prizes durings a calendar year. for each event Check No. ORGANIZATION INFORMATION Organiza name / L PLOSScn Previous lawful gambling exemption number /'l 7ok�J C.J�,n� Type of nonprofit organization. Check (q) one. ❑ Fraternal ❑ Religious ❑ Veterans Other nonprofit organization Mailing address d /,,1 City ��-, 4, State /Zip Code ✓W �"s �t33 County A-7 D lc S Name of It executive officer (CEO) o S� D phone number � 0 y .�.- w�« � �.� PROOF OF NONPROFIT STATUS Check one of the following and attach a copy of your proof of nonprofit status. NOTE: Sales tax exempt status or federal ID employer numbers are not proof of income tax exempt status. _1. Nonprofit Articles of Incorporation _2. Internal Revenue Service - national organization Check if proof previously submitted to Gambling Control Board. OR OR Certificate of Good Standing. — Attach a copy of the IRS income tax exemption [501(c)] letter in your organization's name. To obtain a copy of your federal income tax Attach a copy of your organization's exempt letter, send your federal ID number and the date your Nonprofit Articles of Incorporation organization initially applied for tax exempt status to: OR current Certificate of Good IRS Standing. P.O. Box 2508, Room 4010 Cincinnati, OH 45201 This certificate must be obtained 3. Internal Revenue Service - Affiliate of parent nonprofit each year from: Secretary of State organization (charter) Check if proof previously submitted to Gambling Control Board. Business Services Div. OR 180 State Office Building St. Paul, MN 55155 — If your organization falls under a national organization, attach both Phone: 651 - 296 -2803 of the following: a. a copy of the IRS letter showing that your national organization has been a registered nonprofit 501(c) organization and carries a group ruling, and b. a copy of the charter, or letter from your national organization, recognizing your organization as a subordinate. GAMBLING PREMISES INFORMATION activity will be conducted (for raffles, list the site where the drawing will take place) Name of premises where gambl — ng Address (do not use PO box) J t ,e IV L/' Cit A-� e14 rZ Zip Code ss�a3 Co my �/7 � 1� 7 Date(s) of activity (for raffles, indicate the date of the drawing) A i-, ui 1 1 Check the box or boxes that indicate the type of gambling activity your organization will be conducting: ❑ *Bingo ZL2affles ❑ "`Paddlewheels ❑ "Pull -Tabs ❑ * Tppboards *Gambling equipment for pull -tabs, tipboards, paddlewheels, and bingo (bingo paper, hard cards, and bingo number selection device) must be obtained from a distributor licensed by the Gambling Control Board. To find a licensed distributor, go to www.gcb.state.mn.us and click on List of Licensed Distributors. Or call 6S1- 639 -4000.