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# Dc~e~ ch~~~Pue~ ~'ln~ ~n -~c~d~'tay~. °4`~T SE"``` LOCAL PERMIT OR CHARITY LOCAL PERMIT °f°~,~_„'_` OFFICE OF ATTORNEYGENERAL "~_~ !`~`3~< ~~/~~ SFN 17926 (09-2007) * .ru„.,•.,•~~w,.- -~`"'"`'~~ Type: ^Local Permit *~ Charity Local Permit Permit Number . 432 Name of Organization Ken Kjelland Benefit Date(s) Authorized (Read 'nstru ion ~-al~- `~j'j ~-~Q-~ Contact Person Business Phone Number to -3~?8fz96$' Michelle Aune (701) 371-8x87 Beginning Ending Mailing Address City State Zip Code 506 Sunset Drive Oxbow ND 58047-0000 Site Name Site Address Knickerbocker Liquor Locker 412 Main Avenue City State Zip Code County Hickson ND 58047-0000 Cass Check the Game(s) Authorized: * Poker, Twenty-one, and Paddlewheels may be Conducted only by a Charity Local Permit. Bingo ~ Raffle ~ Calendar Raffle ~ Sports Pool X^ Poker* ~ Twenty-one" ~ Paddlewheels* Restriction: Requirement: Fora "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: ^CityAuditor QX County Auditor Printed Name of City or County Auditor Auditor Telephone Number r 2/17/2009 '~ ~ Michael Montplaisir (701) 241-5600 Please see the InStrU(~IOTSS on the baCKSltle of tnlS torrri on now to complete the Perml[. Far a raffle or calendar raffle, read "Information Required to be Preprinted on a Standard Raffle Ticket" oh the backside of the form. ~~ cut along this line BINGO EXCISE TAX North Dakota Century Code §53-06.1-12(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 Tax to the Office of Attorney General within 30 days from the authorized ending date. Please complete the form below and send with payment to: 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 t~~; ' E ~}x ~` OFFICE OF ATTORNEY GENERAL ,,~.~.~~~~'_>~~-? SFN 58649 (08-2007) Permit Number '~~ ~ =~%J" undefined 4,....KiYkstly." 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.