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Home My WebLink About[4e] Gambling Application . :--:..... - ':- - ..... ", -.,'.-' ,:.'.' '-' , ... -.' ~iQE~'f.Jt)$~;fFl Council Agenda Item L\ eJ MEETING DATE: January 3,2008 AGENDA ITEM: Gambling Permit - Stearns County Thunderin' Toms 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 Lawful Gambling Application for Exempt Permit for the Stearns County Thunderin' Toms for an event to be held at the Trobec's Event Center on March 29, 2008. Minnesota Lawful Gambling Page 1 of 2 6/07 LG220 Application for Exempt Permit For Board Use Only An exempt permit may be issued to a nonprofit organization that: Fee is $50 for Check # . conducts lawful gambling on five or fewer days, and . awards less than $50,000 in prizes during a calendar year. each event $ - ORGAN IZA TION INFORMATION Organization name Previous gambling permit number st e.~".., ~ 1~ U"l6c..-.,,,", \ TOI'1<\E;. X -5~39. C ch.'" oJ... Type of nonprofit organization. f Check (..J) one. D Fraternal D Religious D Veterans ~ Other nonprofit organization Mailing address J. 70 tl.., S }""t"'t ;- I City c.}CJ\.F~ StatelZip Code County 13lJ'Id-. S~ ,l"nh 5"'301 .5t-c"''''.... 5 Name of chief executive officer (CEO) Daytime phone n.umber E J.lA/ A I( () c..... J1 v... v '::J 31...0 3C:.3 .. /20 CJ ATTACH A COPY OF ONE OF THE FOLLOWING FOR PROOF OF NONPROFIT STATUS * Do not attach a sales tax exempt status or federal ID employer numbers as they are not proof of nonprofit status. _ - Non profit 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 - Internal Revenue Service -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, send your federallD number and the date your organization initially applied for tax exempt status to: IRS, P.O. Box 2508, Room 4010, Cincinnati,OH 45201 _Internal Revenue Service - Affiliate of national, statewide, or international parent nonprofit organization (charter) If your organization falls under a parent organization, attach copies of llill!:l of the following: a. IRS letter showing your parent organization is a registered nonprofit 501 (c) organization with a group ruling b. the charter or letter from your parent organization recognizing your organization as a subordinate. ~nternal Revenue Service -proof previously submitted to Gambling Control Board . If you previously submitted proof of nonprofit status from the Internal Revenue Service, no attachment is required. GAMBLING PREMISES INFORMATION Name of Pi?ises where ~ambling activity will be conducted (for raffles, list the site where the drawing will take place) fOb c. c... S c: V'''' t C. ~'" f~- Address (do not use PO box) jJ.... I City I Zip Code I County . 30 'J..15 f/~ 6,.....<.. Sf .fo!:.<,cl.,. sc:, ~ 7,/ 57f:Q."'.... S Date(s) of activity (for raffles, indicate the date of the drawing) 21f4\ 200 V -p ,.,'J-Cav JIt/} /1,( c.. ~ Check the box or boxes that indicate the type of gambling activity your organization will conduct: D *Bingo I2S Raffles 0 *Paddlewheels D *P~II-Tabs D "Tipboards - * Gambling equipment for pull-tabs, tipboards, paddlewheels, and bingo (bingo paper, hard cards, and bingo number selection device) must be obtained from a distJibutor licensed by the Gambling Control Board. To find a licensed distributor, go to www.gcb.state.mn.us and click on Ust of Ucensed Distributors, or call 651-639-4076. LG220 Application for Exempt Permit C3r Page 2 of 2 6/07 LOCAL UNIT OF GOVERNMENT ACKNOWLEDGMENT If. the gambling premises is within city limits, If the gambling premises is located in a township, both the city must sign this application. the swuy and township must sign this application. Check (...J) the action that the city is taking on Check (.J) the action that the county is taking on this application. '. this application. _The application is acknowledged with no waiting period. _The application is acknowledged with no waiting period. _The application is acknowledged with a 3D day waiting _The application is acknowledged with a 30 day waiting period, and allows the Board to issue a permit after 3D period. and allows the Board to issue a permit atter 30 days (60 days for a 1st class city). days. _The application is denied. _The application is denied. Print city name Print county name On behalf of the county, I acknowledge this application. On behalf of the city, I acknowledge this application. Signature of county personnel receiving application Signature of city personnel receiving application. . , Title Date_'_'_ Title Date ~_I- TOWNSHIP: 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 [Minnesota Statute 349.213, subd. 2)] Print township name Signature of township official acknowledging application Tille Date , I CHIEFEXECUTIVE'OFFICER~S SIGNATURE .,. .. : ........:. . ......:..,i., .::. ..:'.: 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 retumed to the Board within 30 days of the date of our gambling activity. " Chief executive officer's signature Date / I Complete an application for,each gambing activity: Financial reportand record keeping . 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 Send application with: activity date, complete and retum the financial . a copy of your proof of nonprofit status, and report form to the Gambling Control Board. . $50 application fee for each event. Questions? Make check payable to "State of Minnesota." 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 Roseville, MN 55113 Data privacy. This form will be made available . in altemative format (Le. 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 your qualffications 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; Attomey General; Commissioners of Administration, Finance, and Revenue; Legislative Auditor, national and intemational 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.