MINNESOTA LAWFUL GAMBLING |
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LG220 Application for Exempt Permit |
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An exempt permit may be issued to a nonprofit organization that: |
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Application fee (non refundable) |
- conducts lawful gambling on five or fewer days, and |
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- awards less than $50,000 in prizes during a calendar year. |
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If application is postmarked or received 30 days or |
If total p ize alue fo |
the yea |
ill e $ |
,5 o less, o ta |
t the li e si |
g |
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more before the event $50; otherwise $100. |
spe ialist assig ed to you ou |
ty. |
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ORGANIZATION INFORMATION |
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Organization name |
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Previous gambling permit number |
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Minnesota tax ID number, if any |
Federal employer ID number (FEIN), if any |
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Type of nonprofit organization. Check one. |
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_____ Fraternal |
_____Religious |
_____Veterans |
_____Other nonprofit organization |
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Mailing address |
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City |
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State |
Zip code |
County |
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Name of chief executive officer [CEO] |
Daytime phone number |
E-mail address |
NONPROFIT STATUS
Attach a copy of ONE of the following for proof of nonprofit status.
_____ 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., 60 Empire Drive, Suite 100, St. Paul, MN 55103
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 the gambling event will be conducted. For raffles, list the site where the drawing will take place.
Address [do not use PO box] |
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City or township |
Zip code |
County |
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Date[s] of activity. For raffles, indicate the date of the drawing. |
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Check each type of gambling activity that your organization will conduct. |
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Bingo* |
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Raffle |
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Paddlewheels* |
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Pull-tabs* |
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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.
LG220 Application for Exempt Permit
LOCAL UNIT OF GOVERNMENT ACKNOWLEDGMENT
CITY APPROVAL for a gambling premises located within city limits
___The application is acknowledged with no waiting period.
___The application is acknowledged with a 30 day waiting period, and allows the Board to issue a permit after 30 days [60 days for a 1st class city].
___The application is denied.
Print city name _______________________________
Signature of city personnel
___________________________________________________
Title ____________________________ Date______________
Local unit of government must sign
COUNTY APPROVAL
for a gambling premises
located in a township
____The application is acknowledged with no waiting period.
____The application is acknowledged with a 30 day waiting
period, and allows the Board to issue a permit after 30 days.
____The application is denied.
Print county name _______________________________
Signature of county personnel
___________________________________________________
Title ____________________________ Date______________
TOWNSHIP. If required by the county.
On behalf of the township, I acknowledge that the organization is applying for exempted gambling activity within the township limits.
[A township has no statutory authority to approve or deny an application, per Minnesota Statutes 349.166.]
Print township name ________________________________
Signature of township officer __________________________
Title ___________________________ Date _____________
CHIEF EXECUTIVE OFFICER’S SIGNATURE
The information provided in this application is complete and accurate to the best of my knowledge. I acknowledge that the financial report will be completed and returned to the Board within 30 days of the event date.
Chief executive officer's signature___________________________________________ Date______________
Print name ________________________________
REQUIREMENTS
Complete a separate application for:
all gambling conducted on two or more consecutive days, or
all gambling conducted on one day.
Only one application is required if one or more raffle drawings are conducted on the same day
Send application with:
__ a copy of your proof of nonprofit status, and
__ application fee (non refundable). Make check payable to "State of Minnesota."
To: Gambling Control Board
1711 West County Road B, Suite 300 South
Roseville, MN 55113
Financial report and recordkeeping required
A financial report form and instructions will be sent with your permit, or use the online fill-in form available at www.gcb.state.mn.us.
Within 30 days of the event date, complete and return the financial report form to the Gambling Control Board.
Questions?
Call the Licensing Section of the Gambling Control Board at 651-639-4000.
This fo |
ill e ade a aila le i alte ai e fo at i.e. la ge p i t, B aille |
upo e |
uest. |
Data privacy notice: The information requested on this
form (and any attachments) will be used by the Gambling
Control Board (Board) to determine your organization’s qualifications to be involved in lawful gambling activities in Minnesota. Your organization has the right to refuse to supply the information; however, if your organization
refuses to supply this information, the Board may not be able to determine your organization’s qualifications and,
as a consequence, may refuse to issue a permit. If your
organization supplies the information requested, the Board will be able to process the application. Your organization’s
name and address will be public information when received by the Board.
All other information provided will be pri- vate data about your organization until the Board issues the permit. When the Board issues the permit, all information provided will become public. If the Board does not issue a permit, all information provided
remains private, with the exception of your organization’s name and address which will
remain public. Private data about your organization are available to: Board mem- bers, Board staff whose work requires
access to the information; Minnesota’s
Department of Public Safety; Attorney
General; Commissioners of Administration, Minnesota Management & Budget, and Revenue; Legislative Auditor, national and international gambling regulatory agencies; anyone pursuant to court order; other indi- viduals and agencies specifically authorized by state or federal law to have access to the information; individuals and agencies for which law or legal order authorizes a new use or sharing of information after this notice was given; and anyone with your written consent.