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Minnesota Lawful Gambling <br />• <br />• <br />• <br />Lease for Pull -Tab, Paddlewheel, Tipboard, and/or Raffle Activity - LG221 <br />Name of Legal Owner of Premises Street Address <br />City State Zip Daytime Phone <br />Name of Lessor Street Address <br />City State Zip Daytime Phone <br />(If same as legal owner, write in "SAME") <br />- xf �� ,t'� f Gcx , //_ -z. �_,e' <br />,� �_�, ,C- 4- tr,� _ems �;iu cis/ f z 4 <br />Name of Leased Premises Street Address <br />City Zip Daytime Phone <br />_rllz. V/' clams 1 00-7 / �1- >� ,;'l' <br />/",- /,", 6)- -/f G% <br />Name of Lessee (name of organization leasing the premises) <br />GCB license no. of organization Daytime Phone <br />���eC'c-i�l �,/EJl jr�.c z l P `�—/- <br />/' ..�6J 3e �� - iT� l � Gy' 7Z L. - s-� <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 />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 />• 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-) le!52 <br />For Premises Permit Renewal Applications Only: If no <br />changes have been made at the site, you do not have to <br />complete this section or provide a sketch. <br />Dimensions <br />The leased areas are: feet by i feet for a total of square feet. <br />feet by feet for a total of <br />feet by feet for a total of <br />Storage feet by feet for a total of <br />Storage feet by feet for a total of <br />Combined total <br />Lawful Gambling Activity <br />square feet. <br />square feet. <br />square feet. <br />square feet. <br />square feet. <br />Type of gambling activity that will be conducted at this gambling premises. Check all that apply. <br />Paddlewheels ® Pull -Tabs 10 RafflesTipboards <br />Term of Lease Amended Lease Unly <br />The term of this lease agreement will be concurrent with <br />the premises permit issued by the Gambling Control <br />Board, unless terminated sooner by mutual consent of <br />the lessor and lessee. <br />Questions on this form should be directed to the Licensing <br />Section of the Gambling Control Board (Board) at 651-639- <br />4000. This publication will be made available in alternative <br />format (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 651-639-4000. <br />If this is an amended lease showing changes occur- <br />ring during the term of the current premises permit, <br />write in the date that the changes will be effective <br />Both parties that signed the lease <br />must initial and date all changes. <br />The information requested on this form will become public <br />information when received by the Board, and will be used to <br />determine your compliance with Minnesota statutes and rules <br />governing lawful gambling activities. <br />Page 1 of 2 <br />1 /99 <br />