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MINNESOTA LAWFUL GAMBLING 6/12 Page 1 of 2 LG220 Application for Exempt Permit An exempt permit may be issued to a nonprofit organization that: Application fee -conducts lawful gambling on five or fewer days,and jf application posted or received: -awards less than $50,000 in prizes during a calendar year. less than 30 days more than 30 days If total prize value for the year will be$1,500 or less,contact before the event before the event the licensing specialist assigned to your county. $100 $50 ORGANIZATION INFORMATION Organization name Previous gambling permit number D b i IL �;,.-. ;1�;� �- '�1 S- i Ze,,. ( . �- X c 3 3 iS -)l - c7o0-1 Minnesota tax ID number, if any Federal employer ID number (FEIN), if any Type of nonprofit organization. Check one. fiFraternal F1 Religious 11 Veterans g Other nonprofit organization Mailing address City State Zip code County 3 7 Liu 13 f?f 1104 C.A"Li 41'41 /y //c A V 5-C// .,�f r Name o chief execu . e officer CEO] ' Daytime phone number E-mail address 7 Pzr c c �(1C �767.1 -,13'-1-c,C� Pew..ja �IS?Iv a-j,,-.-,.1_t NONPROFIT STATUS Attach a copy of ONE of the following for proof of nonprofit status. FLNonprofit 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., 60 Empire Drive, Suite 100, St. Paul, MN 55103 Phone: 651-296-2803 EaIRS 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. 17 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 the gambling event will be conducted. For raffles, list the site where the drawing will take place. Address [do not use PO box] ( City or township Zip code County y D D i0'` S't Aii ) f - - f3r r yh /©A .ci/.a -K4.)-1. Date[s] of activity. For raffles, indicate the date of the drawing. 1 Q cjob C ,.5. '19f&. Check each type of gambling`/ activity that your organization will conduct. Bingo* JC Raffle Paddlewheels* Pull-tabs* Tipboards* *Gambling equipment/ for bingo paper, paddlewheels, pull-tabs, and tipboards must be obtained from a distributor licensed by the Minnesota Gambling Control Board. EXCEPTION: Bingo hard cards and bingo number selection devices may be borrowed from another organization authorized to conduct bingo. To find a licensed distributor, go to www.gcb.state.mn.us and click on Distributors under the WHO'S WHO?LIST OF LICENSEES, or call 651-639-4000.