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Minnesota Lawful Gambling <br />Lease for Pull -Tab, Paddlewheel, Ti board and/or Raffle Activity - LG221 <br />Name of Legal Owner of Premises Street Address City Zip <br />Daytime Phone <br />( ) <br />Name of Lessor Street Address City Zip <br />(If same as legal owner, write in "SAME") /� r�- ./ <br />d{l%J -< ea- „0dea, /-17, 5S77 <br />p2-rr l7fgm %C>i-1 ,if /4i( (P/Le sr,- <br />Daytime Phone <br />( 4.(2 )17f&%77-L <br />Name of Leased Premises Street Address City Zip <br />/P� "72a -Yr �� n -g"1 y / / cCP/N2 , p9:/ ,r3 cr •G 3 „7 <br />Daytime Phone <br />(6,2 > z(c.- - %/t <br />72.10-72771-t Name of Lessee (name of organization leasing the premises) GCB GCC�B license no. of organization <br />- tr -.^-� l/"'. -ei /c7-' o / O 7 0 - °c 0 <br />5�0 /uA_;-..' <br />Daytime Phone <br />( ) <br />Rent Information <br />• Total rent cannot exceed $1,000 per month for all <br />non -bingo activity for this premises. <br />• For bingo activity, use lease form LG222. <br />• For pull -tab dispensing machines, use lease form <br />LG223. <br />• An organization may not pay rent to itself or to <br />any of its affiliates for space used for the conduct <br />of lawful gambling. <br />Rent to be paid per month $ <br />(If no rent is to be paid, indicate -0-) <br />Sketch and Dimensions of Leased Area <br />Sketch: For all areas being leased for the conduct <br />of gambling and storage of gambling product at this <br />premises, attach a sketch (drawing) showing: (1) the <br />leased area(s), and (2) the dimensions. <br />Dimensions <br />The leased areas are: <br />Storage <br />Storage <br />feet by <br />feet by <br />feet by <br />feet by <br />feet by <br />For Premises Permit Renewal Applications Only: If no <br />changes have been made attheslto, you do not have to <br />complete this section or provide a sketch, <br />feet for a total of <br />feet fora total of <br />feet for a total of <br />feet for a total of <br />feet for a total of <br />Combined total <br />square feet. <br />square feet. <br />square feet. <br />square feet. <br />square feet. <br />square feet. <br />Lawful Gambling Activity <br />Type of gambling activity that will be conducted at this gambling premises. Check all that apply. <br />Paddlewheels Pull -Tabs Raffles Tipboards <br />Term of Lease <br />Amended Lease Only <br />The term of this lease agreement will be concurrent with the <br />premises permit issued by the Gambling Control Board, <br />unless terminated sooner by mutual consent of the lessor <br />and lessee. <br />If this is an amended lease showing changes occurring dur- <br />ing the term of the current premises permit, write in the <br />date that the changes will be effective / / <br />Both parties that signed the lease must initial and date all <br />changes. <br />Questions on this form should be directed to the Licensing <br />Section of the Gambling Control Board at (612) 6394000. <br />This publication will be made available in altemative format <br />(i.e. large print, Braille) upon request. Hearing impaired <br />individuals using a TTY may call the Minnesota Relay Service <br />at 1- 800 - 627 -3529 and ask to place a call to (6121639-4000. <br />The information requested on this form will be used by the <br />Gambling Control Board (Board) to determine your compliance <br />with Minnesota statutes and rules governing lawful gambling <br />activities. All of the information that you supply on this form <br />will become public information when received by the Board <br />except, if required, your Social Security number, which remains <br />private. <br />Page 122 <br />Page 1 of 2 <br />Rev. 8/97 <br />