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Minnesota Lawful Gambling Lease for Pull-Tab, Paddlewheel, Tipboard, and/or Raffle Activity - LG221 Name of Legal Owner of Premises Street Address City State Zip Daytime Phone F l a h e r t s A r d e 5': . 1 Cty n Hills PIN 112 state Zip Daytime Phone Name of Lessor Street Address CRY (If same as legal owner,write in"SAME") Same 651/633-1777 Name of Leased Premises Street Address City Zip Daytime Phone (651 ) Flahertys Arden B-owl 1273 IN Cty Ed E 'Arden Hills M Name of Lessee(name of organization leasing the premises) GCB license no.of organization Daytime Phone Lady Slipper Chapter ABWA 03162 651/481—OE-72 Rent Information - Total rent cannot exceed $1,000 per month for all - An organization may not pay rent to itself or to non-bingo activity for this premises. any of its affiliates for space used for the conduct of lawful gambling. For bingo activity, use lease form LG222. - For pull-tab dispensing machines, use lease form LG223. Rent lobe paid per month $ 10 C 0.0 0 (If no rent is to be paid,indicate-0-) Sketch and Dimensions of Leased Area Sketch: For all areas being leased for the conduct For Premises Permit Renewal Applications Only: If no of gambling and storage of gambling product at this changes have been made at the site,you do not have to premises, attach a sketch(drawing) showing: (1)the complete this section or provide a sketch. leased area(s), and (2)the dimensions. Dimensions square feet. The leased areas are: feet by feet for a total of feet by feet for a total of square feet. feet by feet for a total of square feet. Storage feet by feet for a total of square feet. Storage feet by feet for a total of square feet. Combined total square feet. Lawful Gambling Activity Type of gambling activity that will be conducted at this gambling premises. Check all that apply. ® Paddlewheels Pull-Tabs x❑Raffles xl Tipboards Term of Lease Amended Lease Only The term of this lease agreement will be concurrent If this is an amended lease showing changes occur- with the premises permit issued by the Gambling Control ring during the term of the current premises permit, Board, unless terminated sooner by mutual consent of write in the date that the changes will be effective the lessor and lessee. Both parties that signed the lease must initial and date all changes. Questions on this form should be directed to the Licensing The information requested on this form will become public Section of the Gambling Control Board (Board) at 651-639- information when received by the Board, and will be used to 4000. This publication will be made available in alternative determine your compliance with Minnesota statutes and rules format(i.e. large print, Braille)upon request. Hearing impaired governing lawful gambling activities. Page 1 of 2 individuals using a TTY may call the Minnesota Relay Service 1/99 at 1-800-627-3529 and ask to place a call to 651-639-4000.