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Page 1 of 2 06/03
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LC22® Applicati®n ~~r Exempt Permit Fee ~5U - For Board Use Only
'
Fee Paid
Organization Information Check No.
Organization name Previous lawful gambling exemption number
:Church of St.Joseph `7300
Street (mailing, address) City State/zip code County
12 W Minnesota St. St. Joseph MN 56374 Stearns
Name of chief executive officer (CEO) Daytime phone number of CEO
First name Last name Include area code
Fr. Joseph Feders, OSB (320 )363-7505
Name of treasurer Daytime phone number of
First name Last name treasurer. Include area code
Kevin Kluesner, Trustee. (320 )363-7505
.Type of Nonprofit Organization
Check the item that best describes your organization:
. _ Fraternal X Religious
_ Veteran _ Other nonprofit organization
Check the item that indicates the type of proof your organization attached to this application:
IRS letter indicating income tax exempt status (501 c designation)
- Certificate of Good Standing. from the Minnesota Secretary of State's Office Cmust be current
_ A charter showing you are an affiliate of a parent nonprofit organization
Proof previously submitted and on file with the Gambling Control Board
Catholic Directory
Gambling Premises Information
Name of premises where gambling activitywill be conducted (for raffles, fistthe sitewhere the drawing will take place)
Church of St. Joseph ~~
Address (do'not use PO box) City State/zipcode County
12 W Minnesota St. St. Joseph, MN :56374 Stearns
Date(s) of activity (for raffles, indicate the date of the drawing)
July 3 and 4, 2008 Raffle drawing~July 4, 2008
Check the item(s) that indicate the type of gambling activity your organization will be conducting:
X *Bingo X Raffles (cash prizes may not exceed $12,000) X '`Paddlewheels X *Pull-tabs _ *Tipboards
*Equipment for these activities must be obtained from a licensed distributor.
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 your qualifications 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 that you provide
will be private data about you until the
Board issues your permit. When the Board
issues your permit, all of the information
that you have provided to the Board in the
process of applying far your permitwill
become public. If the Board does not issue
you a permit, all the information you have
provided in the process of applying for a
permit remains private, with the exception
of your name and your organization's name
and address which will remain public.
Private data about you are available only to
the following: Board members, staff of the
hoard whose work assignment requires
that they have access to the information;
the Minnesota Department of Public
Safety; the Minnesota Attorney General;
the Minnesota Commissioners of
Administration, Finance, and Revenue; the
Minnesota 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.
LG220 Application for Exempt Permit Page 2 of 2
Church of St. Joseph, St.Jospeh, MN 56374 os/os
Organization Name
Local Unit of Government Acknowledgment
Ifithe gambling-premises is within city limits, the
ci#y must sign this application.
On behalf of the city, I acknowledge this application.
Check the action that
the city is taking on this application.
^ The city approves the application with no
waiting period.
^ The city approves the application with a 30 day
waiting period, and allows the Board to issue a
permit after 30 days (60 days for a first class
city).
The city denies the application.
Print name of city
(Signature of city personnel receiving application)
Title
Date / /
If the gambling premises is located in a township, both
the county and township must sign this application.
On behalf of the county, I acknowledge this application.
Check the action that
the county is taking on this application.
The county approves the application with no
waiting period.
The county approves the applica#ion with a 30 day
waiting period, and allows the Board to issue a
permit after 30 days.
The county denies the application.
Print name of county
(Signature of county personnel receiving application)
Title
Date / /
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 (Minn. Stat. sec.
349.213, subd. 2).)
Print name of township
(Signature oftownship official acknowledging application)
Date / /
Chief Executive Officer's Signature
The information provided in this application is complete and accurate to the best of my knowledge.
Chief executive officer's signature,
Name (please print) F r . Joseph F e d e r s , O S B pate 02 ~ ' ~~ / .~
Mail Application and Attachments
At least 45 days prior to your scheduled activity date send:
• the completed application,
• a copy of your proof of nonprofit status, and
• a check for $50. Make check payable to "State of Minnesota".
Application fees are not prorated, refundable, or transferable.
Send to: Gambling Control Board
1711 West County Road B, Suite 300 South
Roseville, MN 55113