HomeMy WebLinkAbout3K. Exempt Gambling Permit for Rice County Sportfishing Assn June 18, 2013MINNESOTA LAWFUL GAMBLING
LG220 Application for Exempt Permit
3K.
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An exempt permit may be issued to a nonprofit organization that:
Application fee (non refundable)
- conducts lawful gambling on five or fewer days, and
If 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
Org,pp.lzation name a Previous gambling permit number
Minnesota tax ID number, if any Federal employer Id number (FEIN), if any
Type of nonprofit organization. Check one.
- Fraternal -Religious Veterans Other nonprofit organization
fling a dress ) ity State Zip code Co ty
N of chef executive officLer [CEO] Day . phone n tuber 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
NaV
of premises where the pambling event will ted. F r raffles, list the site where the drawing will take place.
ij! or
Addre [do not se PO box] _,C4 or to nship jig code aunty
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Date[s ] activity. For raffles indicate the date of the drawing.
of
Check each type of gambling activity that your organization will conduct.
Bingo* Raffle Paddlewheels* Pull -tabs* Tppboards*
*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
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LOCAL UNIT OF GOVERNMENT ACKNOWLEDGMENT
CITY APPROVAL
COUNTY APPROVAL
for a gambling premises
for a gambling premises
located within city limits
located in a township
_The application is acknowledged with no waiting period.
The application is acknowledged with no waiting period.
_The application is acknowledged with a 30 day waiting
The application is acknowledged with a 30 day waiting
period, and allows the Board to issue a permit after 30 days
period, and allows the Board to issue a permit after 30
[60 days for a 1st class city].
days.
The application is denied.
The application is denied,
Print city name
Print county name
Signature of city personnel
Signature of county personnel
Title Date
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
US
1CcURf I}1�ilt1F,Si
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 applirption is complete and accurate to the best of my knowledge. I acknowledge that the financial
report will be completed and retur o the Board within ay he event date.
Chief executi a officer's signatu eCj %L r Date
Print name _e G Le
REQUIREMENTS
Complete a separate application for:
Financial report and recordkeeping required
+ all gambling conducted on two or more consecutive days, or
A financial report form and instructions will be sent with your
• all gambling conducted on one day.
permit, or use the online fill -in form available at
Only one application is required if one or more raffle drawings
www.gcb.state.mn.us.
are conducted on the same day
Within 30 days of the event date, complete and return
the financial report form to the Gambling Control Board.
Send application with:
_ a copy of your proof of nonprofit status, and
Questions?
application fee (non refundable). Make check payable to
Call the Licensing Section of the Gambling Control Board
"State of Minnesota."
at 651 -639 -4000.
To: Gambling Control Board
This form will be made available in alternative format (i.e. large print, Braille)
1711 West County Road B, Suite 300 South
upon request.
Roseville, MN 55113
Data privacy notice: The Information requested on this All other information provided will be pri- General; Commissioners of Administration,
form (and any attachments) will be used by the Gambling vate data about your organization until the Minnesota Management & Budget, and
Control Board (Board) to determine your organization's Board issues the permit. When the Board Revenue; Legislative Auditor, national and
qualifications to be Involved in lawful gambling activities In issues the permit, all information provided international gambling regulatory agencies,
Minnesota. Your organization has the right to refuse to will become public. If the Board does not anyone pursuant to court order; other indi-
supply the information; however, if your organization issue a permit, all Information provided viduals and agencies specifically authorized
refuses to supply this Information, the Board may not be remains private, with the exception of your by state or federal law to have access to
able to determine your organization's qualifications and, organization's name and address which will the information; individuals and agencies
as a consequence, may refuse to issue a permit. If your remain public. Private data about your for which law or legal order authorizes a
organization supplies the information requested, the Board organization are available to: Board mem- new use or sharing of information after this
will be able to process the application. Your organization's bers, Board staff whose work requires notice was given; and anyone with your
name and address will be public Information when received access to the information; Minnesota's written consent.
by the Board. Department of Public Safety; Attorney