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<br /> <br />LOCAL PERMIT OR CHARITY LOCAL PERMIT <br />OFFICE OF ATTORNEY GENERAL <br />SFN 17926 (09-2007) <br /> <br />"'~""" ~...::;'''' <br />""'0" <br /> <br />Type: <br /> <br />o Local Permit <br /> <br />I Permit Number <br />* 1&1 Charity Local Permit 433 <br />Date(s) Authorized (Read instruction 2) <br /> <br />Name of Organization <br />Relay For Life Team 2 <br />Contact Person <br />Tom Neameyer <br />Mailing Address <br />506 Sunset Drive <br /> <br />Site Name <br />Knickerbocker Liquor Locker <br />City <br />Hickson <br /> <br />Check the Game(s) Authorized: <br /> <br />Business Phone Number <br />(701) 477..3193 <br />City <br />Oxbow <br /> <br />4/17/2009 <br />Beginning <br />I State <br />NO <br /> <br />to 4/19/2009 <br />Ending <br />I Zip Code <br />58047-5012 <br /> <br />Site Address <br />412 Main Avenue <br />State I Zip Code I County <br />ND 58047-0000 Cass <br />, Poker, Twenty-one, and Paddlewheels may be Conducted only by a Charity Local Permit <br /> <br />o Bingo <br /> <br />o Raffle <br /> <br />o Calendar Raffle <br /> <br />o Sports Pool <br /> <br />1&1 Poker' <br /> <br />o Twenty-one' <br /> <br />D Paddlewheels' <br /> <br />Restriction: <br /> <br />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 <br />Attorney General within 30 days of the event <br /> <br />Date <br /> <br />Signature of: DCity Auditor <br /> <br />1&1 County Auditor Printed Name of City or County Auditor <br />Michael Montplaisir <br /> <br />Auditor Telephone Number <br />(701) 241-5600 <br /> <br />3/16/2009 <br /> <br />Please see the instructions on the backside of this form on how to complete the Permit <br />For a raffle or calendar raffle, read "Information Required to be Preprinted on a Standard Raffle Ticket" on the backside of the form. <br /> <br />_ _ _ _ _ _ _ _ _ _ ~talongthisline_ _ _ _ <br /> <br />BINGO EXCISE TAX <br /> <br />North Dakota Century Code ~53-06.1-12(2) requires that organizations who conduct bingo pay an excise tax of three percent on <br />the gross proceeds from the sale at retail of bingo cards to final users. <br /> <br />If the organization conducts bingo under a Local Permit or Charity Local Permit the organization must complete the "Bingo <br />Excise Tax Return for Local Permit or Charity Local Permit" SFN 58649, and submit this form with payment of the Bingo Excise <br />Tax to the Office of Attorney General within 30 days from the authorized ending date. <br /> <br />Gaming Division <br />Office of Attorney General <br />600 E Boulevard Ave. - Dept. 125 <br />Bismarck NO 58505-0040 <br /> <br />Please complete the form below and send with payment to: <br /> <br /> <br />BINGO EXCISE TAX RETURN FOR LOCAL PERMIT OR CHARITY LOCAL PERMIT <br />OFFICE OF ATTORNEY GENERAL <br />SFN 58649 (08-2007) Permit Number <br />undefined <br /> <br /> <br />List the Permit Number assigned on the <br />Local Permit or Charity Local Permit <br /> <br />Bingo Excise Tax Due <br /> <br />$ <br /> <br />X .0291 = <br /> <br />, Bingo Gross Proceeds <br /> <br />* Report the total gross proceeds from the sale of bingo cards during the date(s) authorized on the Permit. <br /> <br />undefined <br /> <br />Name of Organization <br /> <br />Signature of Preparer <br /> <br />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. <br />