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Minnesota Lawful Gambling <br />Pagel of 2 6107 <br />LG220 Application for Exempt Permit <br />Board Use Only <br />Check# <br />An exempt permit may be issued to a nonprofit organization that: Fee IS $50 1 or <br />@ for <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 />PRO ANIZA;TC©N WFORMATJCfA1 7,777 <br />Organization name <br />Previous gambling permit number <br />1-(�OrJ NAGE A.ub gOos'CERS <br />K <br />Type of nonprofit organization. Check (J) one. <br />❑ Fraternal ❑ Religious ❑ Veterans Other nonprofit organization <br />Mailing address <br />City <br />State/Zip Code <br />County <br />Po goX l2o ZYs3 <br />e IES P�A(61-rro J <br />�cAMsa <br />Name of chief executive officer (CEO) <br />Daytime phone number <br />� <br />().)1u.t Arn SQC"A <br />(ota- `3 K5. 4y 5b <br />"#c AcAiPY Of Ok OF I OE FOLLOWWZ FOR AROOF'Of <br />NONPt20F[T ST{t?U8 <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 OR a current Certificate 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 />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 />Internal Revenue Service -proof previously submitted to Gambling Control Board <br />If you previously submitted proof of nonprofit status from the Internal Revenue Service, no attachment is required. <br />GAMBLING PREMISES INFORMATION <br />Name of premises where gambling activity will be conducted (for raffles, list the site where the drawing will take place) <br />LOPJ6 (-RKe (-E&10NAL 'PiIR]c.. <br />Address (do not use PO box) <br />City <br />Zip Code <br />County <br />1500 OLa J -t <br />oc-w �A1Cµ'ro+j <br />x$10- <br />✓nSE <br />Date(s) of activity (for raffies, indicate the date of the drawing) <br />AuGvS t `u uGu ST 9 Aua Ls-lr to 2 -co $ <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.gcb.state.mn.us and click on List of Licensed Distributors, or call 651-639-4076. <br />