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Minnesota Lawful Gambling <br />Page 1 of 2 6/07 <br />LG220Application for Exempt Permit For Boardtseon~y <br />An exempt permit may be issued to a nonprofit organization that: Fee.IS ~50 fOr Check# <br />• conducts lawful gambling on five or fewer days, and <br />• awards less than $50,000 in prizes during a calendar year. each event <br />$ <br />ORGANIZATION INFORMATION <br />Organization name ' Previous gambling permit number <br />Type of nonprofit organization. Check ('~) one. <br />^ Fraternal ~teligious ^ Veterans ^ Other nonprofit organization <br />Mailing address <br />NNW SG <br />~'~2 V <br />~ C' <br />~~~ State/Zip Code <br />M ~ ss303 County <br />~-~ <br />.~ <br />3r~ <br />~ C1 ~ I5 <br />Name of chi~xecutive officer (CEO) Daytime phone number <br />~r-. -f'ct ~.~. ~ ct r o 5 z E'S 1~~ = 7 6 3 - 3 ~..3- ~4~ .~ <br />ATTACH A COPY OF ONE OF THE FOLLOWING FOR PROOF OF NONPROFIT STATUS <br />~ Do not attach a sales tax exempt status or federal ID employer numbers as they are not proof of nonprofit status. <br />Nonprofit Articles of Incorporation ORa currentCertificate of Good Standing. <br />Don't have a copy? This certificate must be obtained each year from: <br />Secretary of State, Business Services Div., 180 State Office. Building, St. Paul, MN 55155 Phone: 651-296-2803 <br />Internal Revenue Service -IRS income tax exemption [501(c)] letter in your organization's name. <br />_ <br />Don't have a copy? To obtain a copy of your federal income tax exempt letter, send your federal ID number and <br />the date your organization initially applied for tax exempt status to: <br />IRS, P.O. Box 2508, Room 4010, Cincinnati, OH 45201 <br />Internal Revenue Service -Affiliate of national, statewide, or international parent nonprofit organization (charter) <br />If your organization falls under a parent organization, attach copies of both of the following: <br />a. IRS letter showing your parent organization is a registered nonprofit 501(c) organization with a group ruling <br />b. the charter or letter from your parent organization recognizing your organization as a subordinate. <br />yr Internal Revenue Service -proof previously submitted to Gambling Control Board <br />~ <br />i <br />d <br />h <br />7 <br />re <br />. <br />ment is requ <br />If you previously submitted proof of nonprofit status from the Internal Revenue Service, no attac <br />GAMBLING PREMISES INFORMATfON <br />'e of premises where gambling activity will be conducted (for raffles, list the site where the drawing will take place) <br />Na~ <br />j <br />t'~-Cr f a ('~- Sc.G~,o-~s <br />Address (do not use PO box) <br />~ qty <br />' Zip Code , <br />~ ~ ~~ County <br />K <br />~ ~,; U F R Aso l ~a ~~ .~ <br />~ <br />Date(s) of activity (for raffles, in irate the d e of the drawing) <br />~~c~~ ~~ / Cr ~~v~ <br /> <br />Check the box or boxes that indicate the type of gambling activity your organization will conduct: <br />*Bingo ~ Raffles. ^ *Paddlewheels ^ *Pull-Tabs ^ *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, go to <br />www.gcbstate.mn.us and click on List of Licensed Distributors, or call 651-639-4076. <br />~• S <br />-LX~ ~ 4 <br />