a. Permit for bingo and raffle - Laserfiche WebLink

LOCAL PERMIT OR CHARITY LOCAL PERMIT OFFICE OF ATTORNEY GENERAL SFN 17926 (09-2007) ," :;.;.:,":":.,{~~: I Permit Number ",,'",,' Type: 181 Local Permit * 0 Charity Local Permit 426 Name of Organization Date(s) Authorized (Read instruction 2) Four Corners Wildlife Club Contact Person Business Phone Number 1/31/2009 to 1/31/2009 Mark Levos (701) 238.3214 Beginning Ending Mailing Address City I State I Zip Code 14659 42nd Street S. E. Wheatland ND 58079-9616 Site Name Site Address Senior Citizen Center R. R. City State I Zip Code I County Embden ND 58079-0000 Cass Check the Game(s) Authorized: . Poker, Twenty-one, and Paddlewheels may be Conducted only by a Charity Local Permit. 181 Bingo 181 Raffle D Calendar Raffle o Sports Pool o Poker' o Twenty-one' o 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 Attorney General within 30 days of the event. Date Signature of: DCity Auditor 181 County Auditor Printed Name of City or County Auditor I Auditor Telephone Number 1/20/2009 Michael Montplaisir (701) 241-5600 Please see the instructions on the 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. 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. 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 Taxto 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 NO 58505-0040 Please complete the form below and send with payment to: 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 Preparer Per N.D. Admin. Code ~99-01.3-01-01, an organization is ineligible for a license or permit if the organization is delinquent in paying any tax.