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Minnesota Lawful Gambling <br />Lease for Pull -Tab, Paddlewheel, Tipboard, and/or Raffle Activity - LG221 <br />Name of Legal Owner of Premises Street Address <br />,. '4 - r` - <br />ame of Lessor Street Address <br />(If same as legal owner, write in "SAME') <br />av 1 a -Y\ 8 NA,Ne Lo- % \\A, .� <br />Name of Leased Premises Street Address <br />P Lta CA CI ta_ •ck Qa <br />Name of Lessee (name of organization leasing the premises) <br />>d Ad r-b•roV e S c \1,9, <br />City <br />State <br />vN <br />L <br />Zip <br />Daytime Phone <br />O t : 1. <br />.I -•a <br />City State Zip Daytime Phone <br />Mn �- -- <br />L: N,c'Lves S So iLl5_ 1104 -2:789 <br />Zip Daytime Phone <br />City <br />UAV-a S 550\t4 5 t St-1- 99 as <br />GCB license no. of organization Daytime Phone <br />1)1-03C0 (054-' -j q - -zz5 <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 pun-tact dispensing machines, use •ease 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 />OOo <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: Q feet by ce3. <br />feet by <br />feet by <br />Storage feet by <br />Storage feet by <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 />feet for a total of <br />feet for a 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 )(1 Pull -Tabs Fre Raffles n Tipboards <br />Term of Lease <br />Amended Lease Only <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 />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 />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 (Le, large,print, Braille), upon request. Haprjp9 Irtipaiced <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 />Thy i\nformatiori_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 />•t199 <br />