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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 State Zip Daytime Phone <br /> Name of Lessor Street Address City State Zip Daytime Phone <br /> (If same as legal owner, write in "SAME") <br /> Name of Leased Premises Street Address City Zip Daytime Phone <br /> Name of Lessee(name of organization leasing the premises) GCB license no.of organization Daytime Phone <br /> Sr Ar►��o.. 11:11a c5 e rJs (30o sief•s ^G Q 4a94 s 412. 789-07 3 l <br /> Rent Information <br /> • Total rent cannot exceed $1,000 per month for all An organization may not pay rent to itself or to <br /> non-bingo activity for this premises. any of its affiliates for space used for the conduct <br /> • For bingo activity, use lease form LG222. of lawful gambling. <br /> • For pull-tab dispensing machines, use lease form <br /> LG223. Rent to be paid per month $ 91)0, 00 <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 For Premises Permit Renewal Applications Only: If no <br /> of gambling and storage of gambling product at this changes have been made at the site,you do not have to <br /> premises, attach a sketch (drawing) showing: (1)the complete this section or provide a sketch. <br /> leased area(s), and (2)the dimensions. <br /> • Dimensions no e�4Nso <br /> The leased areas are: feet by feet for a total of square feet. <br /> feet by feet for a total of square feet. <br /> feet by feet for a total of square feet. <br /> Storage feet by feet for a total of square feet. <br /> Storage feet by feet for a total of square feet. <br /> Combined total 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 Z Raffles 0 Tipboards <br /> Term of Lease Amended Lease Only <br /> The term of this lease agreement will be concurrent with If this is an amended lease showing changes occur- <br /> the premises permit issued by the Gambling Control ring during the term of the current premises permit, <br /> Board, unless terminated sooner by mutual consent of write in the date that the changes will be effective <br /> the lessor and lessee. / / Both parties that signed the lease <br /> must initial and date all changes. <br /> • Questions on this form should be directed to the Licensing The information requested on this form will become public <br /> Section of the Gambling Control Board (Board) at 651-639- information when received by the Board, and will be used to <br /> 4000. This publication will be made available in alternative determine your compliance with Minnesota statutes and rules <br /> format (i.e. large print, Braille) upon request. Hearing impaired governing lawful gambling activities. <br /> individuals using a TTY may call the Minnesota Relay Service Page 1 of 2 <br /> at 1-800-627-3529 and ask to place a call to 651-639-4000. 1/99 <br />