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Min:,esota Lawful Gambling <br /> Lease for Pull -Tab, Paddlewheel, Tipboard, and/or Raffle Activity - LG221 <br /> Name ofL gaIOwnerofPremises Street Address City Zip_ Daytime Phone <br /> Na me of Lessor Street Address city Zip D ytime Phone <br /> (If same as legal owner, write in "SAME") <br /> Name of Leased Premises Street Address city Zip Daytime Phone <br /> �/':o j'/7/,(/ 74Le3yer.�/c�v. /��� �•.f�i� -Y% S5os8( C:S /) ��f16 zY' �' <br /> Name of Lessee (name of organization leasing the remises) GCB license no. of organization Daytime Phone <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 $ 3 �p <br /> (If no rent is to be paid, indicate-D-) <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 atthesite, 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 // <br /> The leased areas are: feet by feet for a total of 7 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 /> T voe of gambling activity that will be conducted at this gambling premises. Check all that apply. <br /> Paddlewheels X Pull -Tabs _Raffles Tipboards <br /> Term of Lease Amended Lease Only <br /> The term of this lease agreement will be concurrent with the If this is an amended lease showing changes occurring dur- <br /> premises permit issued by the Gambling Control Board, ing the term of the current premises permit, write in the <br /> unless terminated sooner by mutual consent of the lessor date that the changes will be effective _/ ! <br /> and lessee. Both parties that signed the lease must initial and date all <br /> changes. <br /> Questions on this form should be directed to the Licensing The information requested on this form will be used by the <br /> Section of the Gambling Control Board at (612) 639 -4000. Gambling Control Board (Board) to determine your compliance <br /> This publication will be made available in alternative format with Minnesota statutes and rules governing lawful gambling <br /> (i.e. large print, Braille) upon request. Hearing impaired activities. All of the information that you supply on this form <br /> individuals using a TTY may call the Minnesota Relay Service will become public information when received by the Board <br /> at 1 -500- 627 -3529 and ask to place a call to (612) 639.4000. except, if required, your Social Security number, which remains <br /> private. <br /> Page 1 of 2 <br /> Rev. 8/97 <br />