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Home My WebLink AboutN [5b] Premise Permit, Pheasants ForeverC1`I'1' AP tiT. J(Rtih 1'H MEETING DATE: January 9, 2009 Council Agenda Item NEW 4b AGENDA ITEM: Gambling Permit -Stearns County Pheasant Forever SUBMITTED BY: Administration BOARD/COMMISSION/COMMITTEE RECOMMENDATION: PREVIOUS COUNCIL ACTION: BACKGROUND INFORMATION: BUDGET/FISCAL IMPACT: ATTACHMENTS: Application for Exempt Permit REQUESTED COUNCIL ACTION: Gambling Application -Accept the Application for Exempt Permit for the Stearns County Pheasant Forever for an event to be held at Gorecki Banquet Center on March 7, 2009. Minnesota Lawful Gambling LC220 Application for Exempt Permit An exempt permit may be issued to a nonprofit organization that: - conducts lawful gambling on five or fewer days, and - awards less than $50,000 in prizes during a calendar year. Page 1 of 2 9/08 Fee is $50 for each event For Board Use Only (:hark # ORGANIZATION INFORMATION Organization name Previous gambling permit number Type of nonprofit organization. Check one. a Fraternal ~ Religious ~ Veterans Other nonprofit organization Mailing address City State Zip Code County Name of chief executive officer (CEO) Daytime phone number Email address 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. 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. ^^ IRS -proof previously submitted to Gambling Control Board If you previously submitted proof of nonprofit status from the IRS, no attachment is required. GAMBLING PREMISES INFORMATION Name of premises where gambling activity will be conducted (for raffles, list the site where the drawing will take place) v Address (do not use PO box) City Zip Code County Date(s) of activity (for raffles, indicate the date of the drawing) Check the box or boxes that indicate the type of gambling activity your organization will conduct: Bingo* Raffles ~Paddlewheels* Pull-Tabs* [~Tipboards* * Gambling equipment for pull-tabs, bingo paper, tipboards, and paddlewheels must be obtained from a distributor licensed by the Also complete Gamblirig 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 651-639-4076. LG220 Application for Exempt Permit Page 2 of 2 9108 LOCAL UNIT OF GOVERNMENT ACKNOWLEDGMENT If the gambling premises is within city limits, If the gambling premises is located in a township, a a city official must check 1X1 the action that the county official must check (X) the action that the county city is taking on this application and sign the is taking on this application and sign the application. A application. township official must also sign the application. _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 period, and allows the Board to issue a permit after 30 days (60 days fora 1st class city). days. _The application is denied. _The application is denied. Print city name Print county name On behalf of the city, I acknowledge this application. On behalf of the county, I acknowledge this application. Signature of county official receiving application Signature of city official receiving application Title Date / / TOWNSHIP: On behalf of the township, I acknowledge that Title Date / / the organization is applying for exempted gambling activity within township limits. [A township has no statutory authority to approve or deny an application [Minnesota Statute 349,213, subd. 2)) Print township name Signature of township official acknowledging application 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 of the date of our gambling activity. Chief executive officer's signature ~ Date % ~ - ®~ --~ ~/ Complete a separate application for each gambing activity: Financial report and recordkeeping - one day of gambling activity, required - two or more consecutive days of gambling activity, A financial report form and instructions will be - each day a raffle drawing is held sent with your permit. Within 30 days of the activity date, complete and return the financial Send application with: a copy of your proof of nonprofit status, report form to the Gambling Control Board. and $50 application fee for each event. Make check payable to "State of Minnesota." Questions? Call the Licensing Section of the Gambling To: Gambling Control Board Control Board at 651-639-4076. 1711 West County Road B, Suite 300 South { print Form R F Roseville, MN 55113 eset orm L.__ Data. privacy. This form will be made available in alternative format{i.e. large print, Braille) upon request. The information requested on this form (and any attachments) will be used by the Gambling Control Board (Board) to determine yourqualifications to be involved in lawful gambling activities in Minnesota. You have the right to refuse to supply the information requested; however, if you refuse to supply this information, the Board may not be able to determine your qualifications and, as a consequence, may refuse to issue you a permit. If you supply the information requested, the Board will be able to process your application. Your name and and your organization's name and address will be public information when received by the Board. All the other information you provide will be private data until the Board issues your permit. When the Board issues your permit, all of the information provided to the Board will become public. If the Board does not issue a permit, all information provided remains private, with the exception of your name and your organization's name and address which will remain public. Private data are available to: Board members, Board staff whose work requires access to the information; Minnesota's Department of Public Safety; Attorney General; Commissioners of Administration, Finance, and Revenue; Legislative Auditor, national and international gambling regulatory agencies; anyone pursuant to court order; other individuals and agencies that are 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 consent.