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n LJ • Minnesota Lawful Gambling Page 1 of 2 6107 LG220 Application for Exempt Permit For Board use only Check# @ An exempt permit may be issued to a nonprofit organization that: Fee IS $5O for • conducts lawful gambling on five or fewer days, and - • awards less than $50,000 in prizes during a calendar year. each event ORGANIZATION INFORMATION Organization name Previous gambling permit number a Type of non rofit organization. Check (�) one. ❑ Fraternal ❑ Religious ❑ Veterans Cfi Other nonprofit organization Mailing address City State/Zip Code County CPQ Fd- 1 tai Name of chief executive officer (CFO) Daytime phone number s' 9&317ZQ-28716 ATTACHA COPY OF OF THE FOLLO FOR PROOF OF NONPROFIT STATUS * Do not attach a sales tax exempt status or federal ID employer numbers as they are not proof of nonprofit status. _ NonprofitArticles of Incorporation OR a current Certificate of Good Standing. Don't have a copy? This certificate must be obtained each year from: Secretary of State, Business Services Div.,. 180 State Office Building, St. Paul, MN 55155 Phone: 651-296-2803 _ Internal Revenue Service - IRS income tax exemption [501(c)] letter in your organization's name. ' Don't have copy? To obtain a copy of your federal income tax exempt letter, send your federal ID number and the date your organization initially applied for tax exempt status to: IRS, P.O. Box 2508, Room 4010, Cincinnati, OH 45201 —internal Revenue Service -Affiliate of national, statewide, or international parent nonprofit organization (charter) If your organization falls under a parent organization, attach copies of b4lh of the following: a. IRS letter showing your parent organization is a registered nonprofit 501(c) organization with a group ruling b. the charter or letter from your parent organization recognizing your organization as a subordinate. —internal Revenue Service - proof previously submitted to Gambling Control Board If you previously submitted proof of nonprofit status from the Internal Revenue Service, no attachment is required. GAMBLING PREMISES INFORMATION Name of premises wheregambling activity will be o9nducted (for raffles, list the site where the drawing will take place) ,�5LAnY �Sic,z E1e �=1,�f.w� Address (do not As PO box) 9.0'7D CDLt City Zip Code 5 .County Date(s) of activity (for raffles, indicate the date of the drawing) Check the box or boxes that indicate the type of gambling activity your organization will conduct: ❑ 'Bingo A Raffles. ❑ 'Paddlewheels ❑ 'Pull -Tabs ❑ •Tipboards * Gambling equipment for pull -tabs, tiplmards, 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 651-639-4076.