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Home My WebLink About[04g] Gambling Permit - Muscular Dystrophy Association <.:rry OF liT. JOS~;I'H Council Agenda Item 4 ~ MEETING DATE: February 7, 2008 AGENDA ITEM: Gambling Permit - Muscular Dystrophy Association 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 Muscular Dystrophy Association for an event to be held at the Stonehouse on June 7, 2008. FROM- ---.. ~ \ @ L-.' 'J C:. '\ , \ " '.'_"", I ---' L......! ~ T-386 P.001/004 F-595 JAN-ZZ-Z008 03:Z8PM ~r 1-1'\~ VL CONFIOENTlAUn' NOTE: The information contained in this facsimile message is legally privileg,ed and confidential Information Intended only for the use of the indj-.,Idual or entity named below. If the reader of this message is not the intended recipient, you are hereby notified that any dissemination, distribution or copy of this facsimile is strictly pro"ibitetl. If you have received this facsimile in 'error. please notify us immediately by telephone and return the original message to us at the address below ...ia the United States Postal Service. Thank you. MUSCULAR DYSTROPHY ASSOCIATION 7401 Metro Blvd. suite 325}1l"'5P Edina, M N 55439 Phone; (952) 832-5517 Fax: (952) 831-1131 C0~2- FAX#: :?1J)- ~?>-~ STATE: .M N DATE: j{ly\ ~!A. NO, OF PAGES (INCLUDING COVER): 3 TO: J U dJ.1 . CITY; ~t, 0OS-e.r'n COMPANY: FROM; M. D-Pc t\zuu ju.~ ,- \ 'Dell elX.. "lt51A- c;PO"'(.L W l+h Lo.,u.,v ~ +r~ jJl Dk ov\ OUY lY"' t.()VJtt~ R~d..e. ~e.ne.-tr\1(\5 MDt\. on Jv-.vv 14h. \...r 'll5U- c.O\Ato\ p\e:.a5.~ Sl~ 'i-\A..Q. Qtio...dN& ~p\iCa;t)OVl -\Do..ppYC\JL U ~ tu h.C.LUL a.. V-O\.~le. -\hlJet WOu..{a\ b.-L ~YeoX ~" f \ea. SL c.oYA- Wi'*'. a.VU-1 q LALsil OVls " K -e.-L~ eu( O;S 2 ~ 8 32 .J ~-q-l i.fJ \ JAN-22-2008 03:28PM FROM- T-386 P.002/004 F-595 Minnesota Lawful Gambling LG220 Application for Exempt Permit An exempt permit may be issued to iii nonprofit organization that: · conducts lawful gambling on five or fewer days, and . · awards less than $50,000 in prizes during a CliIlendar year. ORGANIZATION INFORMATION Organization name Fee is $50 for each event Page 1 0' 2 6/07 For Board Use Only Check# $ ~ Other nonprofit organi?:ation State/Zip Code f.di nCL (VI]I) 55431 Daytime phone number * Do not attach a sales tax exempt status or federal 10 employer numbers as they a~ not proof of nonprofit status. _ NonprofitArticles 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 J.- Internal Revenue Service -IRS Income tax exemption [601(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, Dr international parent nonprofit organi%ation (charter) If your organization falls under a parent organi1:ation, attach copies of J2g1b. of the following: a. IRS letter showing your parent organization is a registered nonprofrt 501(c) organization with a group ruling b. the charter or letter from your parent organization recognizing your organization as a subordinate. . _Internal Revenue Service - proof pl'8viously submiUed to Gambling Control Board . If you previously submitted proof of nonprofit status from the Internal Revenue Service, no attachment is reqUired. GAMBLING PREMISES INFORMATION rs Date(s) of activity (for raffles. indi~ the date of the drawing) < of. ~ Check the box or boxes that indicate the type of gambling activity your organIzation will conduct: D "Bingo i;5a:. Raffles 0 "PClddJewheels 0 "Pull-Tabs D "TJpboards .. Gambling equipment for pull-tabs, tipboards, paddlewheels, and bingo (bingo paper, hard cards, and bingo number selection device) must be obtained from a dIstributor licensed by the Gambling Control Board. To find a licensed distributor, go to www.gcb.state.mn.us and c:lick on Ust of Ucensed Distributors, or call 651-639-4076. JAN-ZZ-Z008 03:33PM FROM- T-386 P.003/004 F-S9S LG220 Application for Exempt Permit Page 2 of 2 6107 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 county and township must sign this application. Cheek <-4> 1he action that the city is taking on Check C...J) the action that the county is taking on @ this application. this application. _The application is acknowledged with no waiting period. _The application is acl<nowledged 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 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 aoknowledge this appliCation. On behalf of the city, I acknowledge this application. Signature of county personnel receiving application Signature of city personnel receiving apprlcation r Title Date '--1 Title Date_--1--1_ TOWNSHIP: On behalf of the townShip. I acknowledge that the organization is applying for exempted gambling actMty within the township limits. [A township has no statutory authority to approve or deny an application [Minnesota Statute 349.213. 5ubd. 2)] Print township name Signature of township official acknowledging application Title Date I ,- CHIEF EXECUTIVE OFFICER"S SIGNATURE The informatIon provided in this applioation is complete and accurate to the best of my knowledge. I aoknowledge that the financial report wI71 be completed anel returned ~rd within 30 days of the date of our gambling aotivity. Chief executive officer's signature CC"""- . Date II , ~/ I cr1 Complete an 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 instnlctions 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 stat\Js, and report form to the Gambling Control Board. . $50 application fee for each event. Questions? Make check payable to "State of Minnesota." Call the Licensing Section of the Gambling To: Gambling Control Board Control Board at 651-639-4076. 1711 West County Road B, Suite 300 South Roseville, MN 55113 Data privacy. Thi$ form Will be made available in 3ltemalive fonnat O.e.large print, Blame) upon request. The irlfOlTTlafion requested on this form (end any attachments) wil be u&ed by 1he Gambling Control Board (Board) to determine your qua"cations to be Involved In Iawf1,JI gambrlflQ actlvItles In Mirlnesota. You have the right to refu5e to 5l4lPly the InfoImaliOn requested: howevBt. if you refuse to supply this infom1a\iQn. the Board may not be able to determine your qualifications antf. 8S a consaquenCle, may refuse 10 Issue you a permit If you supply lI'Ie informeticn requested. the Balii'd wm be able to process ~our applica1ion. Your nama Me! and your organization'6 name and address wlh be pvblic Infonnallon When me;alved by tl1e Board. All 1M other information you provide wiI be private .jala until the Board /sslJes your permit. \NIlen 1M Board issues )'QUI" permit. all of the Information provided to !he Soard will ~me public. If the Board does not issue a permit, aI information provided remains private, wi1h the nxmptlon of )'Qur name and your organlzallon's name and address whlcn will remain public. Private da1a are available to: Board members. Board staff whose work requires access to the Information; Mlnnesota'S Department of Publlc Safely; AtIomey General: CommIssionen; of AdmInistration, Financs, and Revenue; Legislative Auditor, na\iQnal and inlemational gambling regulatory agendas; anyone pun;uant to COtJrt Otder; otner incflVidua(s and agencies that are spedficaUy aUlhcli%ad by stale or federall<lw to have access to the information; Ind1vIclJaIs and agencie$ for which law or legal order lIulhtmes a new use or sharing of information aller IhlS Notice W<l$ gillen; and anyone with )'Qur consent