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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 City Zip Daytime Phone <br />- lam #7,) /ef 7 8 . 5 / knoll br. )-,Ho 1-4,4es mot /SSo /y( d /.Z )78 i / -L /9' <br />Name of Lessor Street Address City Zip Daytime Phone <br />(If same as legal owner, write in "SAME ") <br />ar,t -s V)'l, t itr 78—C1 kr•o I) b r. )-i,o Ln.L{s, M,J s:.i D/Y ( b /� )78N- 68l 9 <br />Name of Leased Premises Street Address City Zip Daytime Phone <br />Mi lltts on n 4t;0) &t o i_ LL c br. L t,0 Lo -Kts/ /mid -s-3-0/ Ll ( 6 /.z )71'2- 7/0(2 <br />Name of Lessee (name of organization leasing the premises) GCB license no. of organization Daytime Phone <br />n/ <br />rtn4ennied Pir3. Q4i;vc AIICe. 2-pa0/7 (6 /.t )ley -74(7.2 <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-) � A <br />/ �� <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: feet by <br />feet by <br />feet by <br />Storage 3 feet by <br />No <br />Storage <br />C.ka.n9 t s %lout <br />feet by <br />be ti.»•Jt, <br />F r ;Premises :Perm t.Rer ew l <br />changes have been made at tip <br />complete this section or prow <br />feet for a total of 3 0 square feet. <br />feet for a total of square feet. <br />feet for a total of square feet. <br />feet for a total of 6 square feet. <br />feet for a total of square feet. <br />Combined total 3 tQ 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 X Pull -Tabs X Raffles <br />X 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 7 / / / 9$ . <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) 639 -4000. <br />This publication will be made available in alternative 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 (612) 639 -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 goveming 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 1 of 2 <br />Rev. 8/97 <br />