LG220 Application for Exempt Permit
LOCAL UNIT OF GOVERNMENT ACKNOWLEDGMENT (required before submitting application to
the Minnesota Gambling Control Board)
CITY APPROVAL
for a gambling premises
located within city limits
____ The application is acknowledged with no waiting period.
____ The application is acknowledged with a 30-day waiting
period, and allows the Board to issue a permit after 30 days
(60 days for a 1st class city).
____ The application is denied.
Print City Name: ______________________________________
Signature of City Personnel:
___________________________________________________
Title:____________________________ Date:______________
COUNTY APPROVAL
for a gambling premises
located in a township
____The application is acknowledged with no waiting period.
____The application is acknowledged with a 30-day waiting
period, and allows the Board to issue a permit after
30 days.
____The application is denied.
Print County Name: ___________________________________
Signature of County Personnel:
___________________________________________________
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 an application, per Minn. Statutes, section 349.213.)
Print Township Name: _________________________________
Signature of Township Officer:___________________________
Title: ___________________________ Date: ______________
CHIEF EXECUTIVE OFFICER’S SIGNATURE (required)
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 30 days of the event date.
Chief Executive Officer's Signature: ____________________________________________________ Date: ___________________
(Signature must be CEO’s signature; designee may not sign)
Print Name: _______________________________________________________________________________________________
REQUIREMENTS MAIL APPLICATION AND ATTACHMENTS
Complete a separate application for:
all gambling conducted on two or more consecutive days; or
all
gambling conducted on one day.
Only one application is required if one or more raffle drawings are
conducted on the same day.
Financial report to be completed within 30 days after the
gambling activity is done:
A financial report form will be mailed with your permit. Complete
and return the financial report form to the Gambling Control
Board.
Your organization must keep all exempt records and reports for
3-1/2 years (Minn. Statutes, section 349.166, subd. 2(f)).
Mail application with:
____ a copy of your proof of nonprofit status; and
____ application fee (non-refundable). If the application is
postmarked or received 30 days or more before the event,
the application fee is $100; otherwise the fee is $150
.
Make check payable to State of Minnesota.
To: Minnesota Gambling Control Board
1711 West County Road B, Suite 300 South
Roseville, MN 55113
Questions?
Call the Licensing Section of the Gambling Control Board at
651-539-1900.
The city or county must sign before
submitting application to the
Gambling Control Board.
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Data privacy notice: The information requested
on this form (and any attachments) will be used
by the Gambling Control Board (Board) to
determine your organization’s qualifications to
be involved in lawful gambling activities in
Minnesota. Your organization has the right to
refuse to supply the information; however, if
your organization refuses to supply this
information, the Board may not be able to
determine your organization’s qualifications and,
as a consequence, may refuse to issue a permit.
If your organization supplies the information
requested, the Board will be able to process the
application. Your organization’s name and
address will be public information when received
by the Board. All other information provided will
be private data about your organization until the
Board issues the permit. When the Board issues
the permit, all information provided will become
public. If the Board does not issue a permit, all
information provided remains private, with the
exception of your organization’s name and
address which will remain public. Private data
about your organization are available to Board
members, Board staff whose work requires
access to the information; Minnesota’s Depart-
ment of Public Safety; Attorney General;
Commissioners of Administration, Minnesota
Management & Budget, and Revenue; Legislative
Auditor, national and international gambling
regulatory agencies; anyone pursuant to court
order; other individuals and agencies 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 written consent.
This form will be made available in alternative format (i.e. large print, braille) upon request.
An equal opportunity employer
