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. . '. Page1of2 Minnesota La'l"ful Gambling 5/01 LG221 ~.ea~e for Pull-Tab, Paddl.ewhee.l, Tipboard, and/or Raffle Activity. Name ofLeg81 Owt1er of Premises' Street Address City State Lip Daytime Plione ~ a '(;S-I 7 Zip aytime Phone 1. Total rent cannot exceed $1,000 per.month for all non-bingo activity for this premises. 2. For bingo activity, use lease form LG222. . , . 3. For pull-tab dispensing machines., use lease form LG223. . . ' Sketch and Dimensions of Leased.Area Sketch. For all areas being leased for .the conduct of gambling and storage of gambling pr~duct at this premises, attach a'sketch (drawing) showing: (1) the leased area(s), and (2) the dimensions. Dimensions The leased areas are: q Q feet by 7 . ' feet by. 7 feet ~y . feet by feet by Storage Storage 4. An organization may not pay r:ent to itself or to any of its affiliates for space used for the conduct of lawfur gambling. . 5. Rent to be p~id per month $ IIJC) 0 If no rent is to be paid, ,indicate -0- For Premises Permit R.newal Applications Only: If no changes h~ve been made at the sit~, you 'do not have to complete this section or provide a sk~tch. feet for a total of feet for a total of feet for a total of feet for a total of feet for a total of Combined total ~,3 Ilf square feet. square feet. square feet. square feet. square feet. square feet. 7~ . Lawful Gambling Acti~ity . Type of gambling activity that will be conducted at this gambling premises. Check all that apply. ~ Paddlewheels j0!lIl1-Tabs ~affles . , Term of Lease Amended Lease Only The term of this lease agreement will be concurrent with If this is an amended lease showing changes occur- the. premises p~rmit 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. . ---1---1_. B~th parties that. signed the lease must initial and date all changes. Questions on this form'should be directed to the Licensing Section of the Gambling Control Board (Board) at 651-639- 4000. This publication will be made available in alternative format (i.e. large print, Braille) upon request.lf you use. a ~ you can call the Board by using the Minnesota ~elay Service and ask to place a call to .651-639-4000. The information requested on this form wiil become public information when received by the Board, and will be used to determine your compliance with Minnesota statutes and rules governing lawful gambling activities.