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Minnesota Lawful Gambling Page 1 of 2 1111 Application fee for each event LG220 Application for Exempt Permit i apolication postmarked or received: An exempt permit may be issued to a nonprofit organization that: less than 30 days more than 30 days -conducts lawful gambling on five or fewer days,and before the event before the event -awards less than$50,000 in prizes during a calendar year. $100 $50 ORGANIZATION INFORMATION Check# $ Organization name Previous gambling permit number N b irn'V.ir0 \ir0 J e t_S X,g� 7/ Type of nonprofit organization. Check one. Fraternal Religious Veterans Other nonprofit organization Mailing address City State Zip Code County 1 o(eD tk)est LM Toss l.v ss- i/-3 Name of chief executive officer(CEO) Daytime phone number Email addre v1 ativn_t-f-t-\/ Attach a copy of ONE of the following for proof of nonprofit status. Check one. `Do not attach a sales tax exempt status or federal ID employer numbers as they are not proof of nonprofit status. �C Nonprofit Articles 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 IRS income tax exemption[501(c)]letter in your organization's name. Don't have a copy? To obtain a copy of your federal income tax exempt letter,have an organization officer contact the IRS at 877-829-5500. IRS-Affiliate of national,statewide,or international parent nonprofit organization(charter) If your organization falls under a parent organization,attach copies of both of the following: a. IRS letter showing your parent organization is a nonprofit 501(c) organization with a group ruling, and b. the charter or letter from your parent organization recognizing your organization as a subordinate. GAMBLING PREMISES INFORMATION Name of premises where gambling activity will be conducted(for raffles,list the site where the drawing will take place) L Dnq Leat l a9 inia Pa r-k Address(do ndt use PO box) City Zip Code County /5-00 Old !-f 7qh r car ti e iUii ) )3 oqk 7hr) fri lki Date(s)of activity(for raffles,indicate the date of the drawl ) I✓IAll /L/ aO r r Check the box or boxes that indicate the type of gambling activity your organization will conduct: ❑ Bingos Raffles ❑Paddlewheels* ❑Pull-Tabs* DTipboards* *Gambling equipment for pull-tabs, bingo paper,tipboards,and paddlewheels must be obtained from a distributor licensed by the Also complete Gambling Control Board. EXCEPTION: Bingo hard cards and bingo Page 2 of this form. number selection devices may be borrowed from another organization authorized to conduct bingo. Print Form To find a licensed distributor,go to www.gcb.state.mn.us and click on List Reset Form of Licensed Distributors,or call 651-639-4000.