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Premises Information Name and Address of Lessor - Address City/Zip Code Phone 3— �r7 C7, A24 -a e i -Y Gi' -4.� .�.r . ,t�:'�e..r (, x. ) . q.'S/ 7l1s Name of Legal Owner of Gambling Premises Address City/7p Code Phone me and Address of Leased Premises _. Address City/Zip Code • Name of Organization Leasing the Premises (lessee) • v' -& Q-7 Gambling License Number, if known n`// c /tfl The lawful gambling activity which the organization will conduct is (check all that apply): : I 1 bingo raffles 1 I paddlewheels I I pull -tabs I 1 tipboatds Rent Information (See Rules 7860.0090, Subp 3) Class A and C premises permits: Rent for bingo and all other gambling activities conducted during that bingo occasion may not exceed: $200 for up to 6,000 square feet; $300 for up to 12,000 square feet; and $400 for more than 12,000 square feet. Rent to be paid per •iiapo occasion $ Q'D Class B and D premises permits: Rent for gambling activities not including bingo is a maximum of $1000 per month. Rent to be paid per month % Rent may not be based on a- percentage of receipts, profits from lawful gambling, or on the number of participants attending a bingo occasion. - M organization may not pay rent to itself or to any of its affiliates for space used for the conduct of lawful gambling. PremLSes;:DescrxptYOn The area(s) leased within the premises are -feet by - feet, for a total of °square feet. feet by feet, for a total of square feet.' . • ""feet by :feet, for a total of square feat. ; Sketch Attach a sketch which shows the location and dimensions of the leasedareas. Effective'Dates .. The lease will go into effect at 12:01 a.m. on 19 . and will end at 12:00 am on 19 for a period of at least one year. 4." - • - rimes and Da s a Bin o Activi y � f g � {tt none,lndtcata`N/Aj . n N/A� :The bingo occasions will be held (a maximum of 7 bingo occasions per organization):_ -_ from (hours) (a.mJp.m.) to (a.mJp.m.) on (days of week) from (hours) (a.mJp.m.) to ' i T (a.m./p.m.) on (days of week) from (hours) (a.mJp.m.) to (a.mJp.m.) on (days of week) Combined total' ' `square feet from (hours) (a.mJp.m.) to 1 on (days of week) from (hours) (a.mJp.m.)'to on (days of week) y ".;. Page 4 from (hours) (a.mJp.m.)--to ' g on (days of week) from (hours) (a.mJp.m.)rto .) on (days of week)