STATE OF NEVADA GAMING CONTROL BOARD 1919 E. College Parkway, P.O. Box 8003, Carson City, Nevada 89702 555 E. Washington Ave., Suite 2600, Las Vegas, Nevada 89101 3650 South Pointe Cir., P.O. Box 31109, Laughlin, Nevada 89028 557 W. Silver St., Suite 207, Elko, Nevada 89801 6980 Sierra Center Parkway, Reno, Nevada 89502 750 Pilot Road, Suite H, Las Vegas, Nevada 89119 JIM GIBBONS Governor DENNIS K. NEILANDER, Chairman RANDALL E. SAYRE, Member MARK A. LIPPARELLI, Member CHARITABLE LOTTERIES APPLICATION FOR APPROVAL OR REGISTRATION Applicants are responsible for complying with state laws related to charitable lotteries, specifically NRS 462 and 463. Organization Name: Street Address: City, County, State, Zip Code: Non-Profit or Charitable Status of Organization: *Please submit proof with application [Ex. 501 (c) (3)] Contact Person: Telephone: Signature: Date: By signing this application, the applicant certified that, pursuant to Nevada Statutes, the proceeds of the charitable lottery will be expended only for the benefit of charitable or nonprofit activities in the State of Nevada. Is this an application for registration or approval for a charitable lottery? (Check below.) REGISTRATION – required if the total value of all prizes offered in charitable lottery activities operated by your organization exceed $2,500 in a calendar year, but do not exceed $25,000 during the same calendar year ($5 fee). APPROVAL – required if the total value of all prizes offered in charitable lottery activities operated by your organization exceed $25,000 in a calendar year, but do not exceed $500,000 during the same calendar year ($25 fee). No application is required if:  The total value of prizes does not exceed $2,500 and your organization operates no more than two charitable lotteries per year; OR  The total value of prizes does not exceed $2,500 and the tickets or chances are sold only to members of your organization, and to guests of those members while attending a special event sponsored by your organization, and the total value of all the prizes offered in charitable lotteries operated by your organization during the same calendar year does not exceed $15,000. ENF-115 (Rev. 08/10) American LegalNet, Inc. www.FormsWorkFlow.com Charitable Lottery Application Page 2 Officers/Board of Directors: Name: Title: Telephone: Persons responsible for operation of the charitable lottery and their relationship to the organization (i.e., member, volunteer, employee, independent contractor, etc.): Name: Relationship to Organization: Telephone: Description of lottery: Prizes awarded (Please specify type/description of prizes and amount/value): **If value of any prize is valued over $1,000, you MUST include proof of prize and its value, (ex. receipt, bill of sale): Name the primary county in which the charitable lotteries will be conducted: Date ticket sales begin: Date, Time & Place of Drawing: Describe the intended use of net proceeds from this charitable lottery. Indicate the approximate percentage of proceeds which will be allocated to various uses such as activities, equipment, supplies, transportation, salaries, general administrative costs, etc.: **State law provides that sales of tickets or chances for a charitable lottery must be in the primary county or Nevada counties that border on the primary county. **Ticket sales outside Nevada are prohibited. **ONLINE ticket sales are prohibited. ENF-115 (Rev. 08/10) American LegalNet, Inc. www.FormsWorkFlow.com Charitable Lottery Application Page 3 If this is a request for approval (NOT registration), what are the anticipated expenses of conducting this lottery? (Attach copies of any proposed agreements between your organization and any suppliers of material for the operation of your lottery.) Please attach the following documents: Proof of charitable or nonprofit status (Ex. 501(c) (3) or Nevada tax exempt certificate). Nonrefundable fee in the form of a check or money order made payable to the Gaming Control Board. ($5 for registration or $25 for approval). If you are requesting approval (NOT registration), copies of proposed agreements with supplies of material for the operation of your lottery. Proof of prizes valued over $1,000. Applications must be submitted 30 days prior to the commencement of any lottery activity, including advertising or ticket sales. Organizations are encouraged to file applications earlier than the required 30 days. Questions regarding the application process may be directed to the Enforcement Division, Operations Unit in Las Vegas (702) 486-2564. Mail application and fees to: Gaming Control Board Enforcement Division Operations Unit 555 East Washington Avenue, Suite 2600 Las Vegas, Nevada 89101 Under Nevada Revised Statute 462: ♦In the category which requires approval, organizations are limited to one charitable lottery during each calendar quarter unless specifically authorized by the Chairman of the Gaming Control Board. ♦If this is a request for approval (NOT registration), after completion of your lottery and no later than the end of the same calendar year, your organization must submit a financial report to the Chairman of the State Gaming Control Board (c/o Enforcement Division–Las Vegas). The financial report must include a statement of expenses incurred in the operation of the charitable lottery, and the amount and use of net proceeds of the charitable lottery. ENF-115 (Rev. 08/10) American LegalNet, Inc. www.FormsWorkFlow.com