c. Permits for raffle - Laserfiche WebLink

, sr4f. , 1,1 APPLICATION FOR A LOCAL PERMIT OR CHARITY LOCAL PERMIT l` ''} ,� OFFICE OF ATTORNEY GENERAL rye SFN 9338(07-2009) cti • Application for: ❑ Local Permit * p Charity Local Permit (one event per year) Name of Non-profit Organization Date(s)of Activity The Sylstad Family Benefit 7/18/2014 to 7/18/2014 Person Responsible for the Gaming Operation and the isbursement of Net Income r Title Business Phone Number Amanda Hartmann 41b 0/126a-Mid Secretary (701)403-9282 Business Address City State Zip Code 106 1st St West Fargo ND 58078-1835 Mailing Address(if different) City State r Zip Code Name of Site Where Game(s)will be Conducted Site Address Red River Valley Fairgrounds 1805 Main Ave City State Zip Code County West Fargo ND 58078-1341 Cass Check the Game(s)to be Conducted: *Poker,Twenty-one,and Paddlewheels may be Conducted only by a Charity Local Permit. ❑Bingo © Raffle ['Calendar Raffle ❑Sports Pool ❑Poker* ❑Twenty-one* ❑ Paddlewheels" DESCRIPTION AND RETAIL VALUE OF PRIZES TO BE AWARDED Retail Value of Retail Value of Game Type Description of Prize Game Type Description of Prize Prize Prize 50/50 Raffle Cash $600.00 Square Board Garr iPad Mini $300.00 Square Board Garr Flat Screen TV $520.00 Raffle ($1 tickets) Various donation $5,000.00 (Limit$12,000 per year) Total: $ 6,420.00 Intended uses of gaming proceeds:Michael and Brittany Sylstad will use the proceeds to help pay for medical bills already incurred and for ongoing care for their preemie newborn,who will be in the NICU for several months. Does the organization presently have a state gaming license? © No ❑Yes - If"Yes,"the organization is not eligible for a local permit or charity local permit and should call the Office of Attorney General at 1-800-326-9240. Has the organization received a charity local permit from this or another city or county for the fiscal year July 1 through June 30? © No ❑ Yes- If"Yes," the organization does not qualify for a local permit or charity local permit. Has the organization received a local permit from this or another city or county for the fiscal year July 1 through June 30? l3 No ❑ Yes - If"Yes," indicate the total value of all prizes previously awarded:$ . This amount is part of the total prize limit of$12,000 per year. Sign• . e of Orgzatio 's op ecutive Official Date Title Business Phone Number VI , � 2i ,i4 Secretary (701)403-9282