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o LOCAL PERMIT OR CHARITY LOCAL PERMIT OFFICE OF ATTORNEY GENERAL SFN 17926 (09-2007) Type: o Local Permit * !RI Charity Local Permit Permit Number 428 Name of Organization The Relay For Life Contact Person Tom Neameyer Mailing Address P. O. Box 280 Date(s) Authorized (Read instruction 2) Business Phone Number (701) 477-3193 City Rolla 12/12/2008 Site Name Site Address Knickerbocker Liquor 412 Main Avenue City State Zip Code County Hickson NO 58047-0000 Cass Check the Game(s) Authorized: "Poker, Twenty-one, and Paddlewheels may be Conducted only by a Charity Local Permit. to 12/14/2008 Ending Zip Code 58367-0280 D Bingo D Raffle D Calendar Raffle o Sports Pool lEI Poker" o Twenty-one" D Paddlewheels" Restriction: Requirement: For a "Charity Local Permit," the organization must file a "Report on a Charity Local Permit" with the city or county auditor and Office of Attomey General within 30 days of the event. 11/17/2008 Michael Montplaisir (701) 241-5600 Please see the instructions on e backside of this form on how to complete the Permit. For a raffle or calendar raffle, read "Information Required to be Preprinted on a Standard Raffle Ticket" on the backside of the form. Printed Name of City or County Auditor Auditor Telephone Number Date cut along this line -------------------------- BINGO EXCISE TAX North Dakota Century Code 953-06.1-12(2) requires that organizations who conduct bingo pay an excise tax of three percent on the gross proceeds from the sale at retail of bingo cards to final users. Please complete the form below and send with payment to: If the organization conducts bingo under a Local Permit or Charity Local Permit the organization must complete the "Bingo Excise Tax Return for Local Permit or Charity Local Permit" SFN 58649, and submit this form with payment of the Bingo Excise Tax to the Office of Attorney General within 30 days from the authorized ending date. Gaming Division Office of Attorney General 600 E Boulevard Ave.. Dept. 125 Bismarck ND 58505-0040 BINGO EXCISE TAX RETURN FOR LOCAL PERMIT OR CHARITY LOCAL PERMIT OFFICE OF ATTORNEY GENERAL SFN 58649 (08-2007) Permit Number undefined List the Permit Number assigned on the Local Permit or Charity Local Permit Bingo Excise Tax Due $ X .0291 = " Bingo Gross Proceeds " Report the total gross proceeds from the sale of bingo cards during the date(s) authorized on the Permit. undefined Name of Organization Signature of Pre parer Per N.D. Admin. Code 999-01.3-01-01, an organization is ineligible for a license or permit if the organization is delinquent in paying any tax.