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• <br />0 <br />11 <br />Minnocnt� I awfill %�mhlinn <br />Page 1 of 2 2/10 <br />----� -- �-—��-� <br />LG220 Application for Exempt Permit <br />Application fee for each event <br />If application Dostmarked or received: <br />less than 30 days <br />more than 30 days <br />An exempt permit may be issued to a nonprofit organization that: <br />- conducts lawful gambling on five or fewer days, and <br />before the event <br />before the event <br />- awards less than $50,000 in prizes during a calendar year. <br />$100 <br />$50 <br />ORGANIZATION INFORMATION Check # $ <br />Organization name Previous gambling permit number <br />St. John the Baptist Catholic Church 62159 <br />Type of nonprofit organization. Check one. <br />E] Fraternal Religious Veterans 1:1 Other nonprofit organization . <br />Mailing address City State Zip Code County <br />835 2nd Avenue NW New Brighton MN 55112 Ramsey <br />Name of chief executive officer (CEO) Daytime phone number Email address <br />(Rev.) Michael Skluzacek 651-633-8333 stjohnsnb@pclink.com <br />Attach a copy of ONE of the following for proof of nonprofit status. Check one. <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 />F-1 <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 />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, have an organization officer <br />contact the IRS at 877-829-5500. <br />F] IRS - 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 nonprofit 501(c) organization with a group ruling, and <br />b. the charter or letter from your parent organization recognizing your organization as a subordinate. <br />aIRS - proof previously submitted to Gambling Control Board <br />If you previously submitted proof of nonprofit status from the IRS, 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 />St. John the Baptist Parish School <br />Address (do not use PO box) City Zip Code County <br />845 2nd Avenue NW New Brighton 55112 Ramsey <br />Date(s) of activity (for raffles, indicate the date of the drawing) <br />April 27,2010 <br />Check the box or boxes that indicate the type of gambling activity your organization will conduct: <br />Bingo* ® Raffles ❑ Paddlewheels* ❑ Pull -Tabs* E]Tipboards* <br />* Gambling equipment for pull -tabs, bingo paper, tipboards, and <br />Also complete <br />paddlewheels must be obtained from a distributor licensed by the <br />Gambling Control Board. EXCEPTION: Bingo hard cards and bingo Page 2 of this form. <br />number selection devices may be borrowed from another organization <br />authorized to conduct bingo. Pram Foran <br />To find a licensed distributor, go to www.gcb.state.mn.us and click on List 13es2otrri <br />Licensed Distributors, <br />of or call 651-639-4076. <br />