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Minnesota La wfui Gambling <br />Lease for Puli-Tab, Paddlewheel, Tipboard, and/or Raffle Activity - LG22' <br /> <br />Name of Legal Owner of Premises Street Address <br /> <br />Name of Lessor Street Address <br />(If same as legal owner, write in "SAME'~ <br /> <br />Name of Leased Premises Street Address <br /> <br />~lame of Lessee (name of organization leasing the premises) <br /> <br /> City State Zip Daytime Phone <br /> '7,5 :Y - <br /> <br /> C~y State Zip ~a~ime Phone <br /> <br />C~ Zip ~a~ime Ph~e <br /> <br /> GCB license no. ¢ organ~i~ Da~ime Ph~e <br /> <br />I <br />I <br />I <br />I <br />I <br /> <br />Rent Information <br /> <br /> · Total rent cannot exceed $1,000 per month for all <br /> non-bingo activity for this premises. <br /> <br /> · For bingo activity, use iease form LG222. <br /> <br /> · For pull-tab dispensing machines, use lease form <br /> LG223. <br /> <br />Sketch and Dimensions of Leased Area <br /> <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 /> <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 /> <br />Rent to be paid per month $ j'~2 d ¢, O 0 <br />(If no rent ~s to be paid, indicate -0-) <br /> <br />IFor Premises Permit Renewal Applications Only: If no <br />changes have been made at the site, you do not have to <br />complete this section or provide a sketch. <br /> <br />leased area(s), and (2) the dimensions. <br /> <br />Dimensions <br />The leased areas are: ~ feet by <br /> feet by <br /> feet by <br />Storage feet by <br />Storage feet by <br /> <br />/0 <br /> <br />feet for a total of <br />feet for a total of <br />feet for a total of <br />feet for a total of <br />feet for a total of <br />Combined total <br /> <br /> square feet. <br /> square feet. <br /> square feet. <br /> <br />. square feet. <br /> <br /> square feet. <br /> square feet. <br /> <br />Lawful Gambling Activity <br /> <br /> Type of gambling activity that will be conducted at this gambling premises. Check all that apply ....... <br /> <br />I <br />i <br />I <br />I <br /> <br />I <br />I <br />I <br /> <br />Term of Lease Arrtended Lease .Only , , <br /> <br />The term of this lease agreement will be concurrent <br />with the premises permit issued by the Gambling Control <br />Board, unless terminated sooner by mutual consent of <br />the lessor and lessee. <br /> <br />If this is an amended lease showing changes occur- <br />ring during the term of the current premises permit, <br />write in the date that the changes will be effective <br />__/__/__. Both parties that signed the lease <br />must initial and date all chan~es. <br /> <br />Questions on this form should be directed to the Licensing The [nf. ormation requested on this form will become public <br /> <br />I <br />I <br />I <br /> <br />Section of the Gambling Control Board (Board) at 651-639- <br />4000. This publication will be made available in alternative <br />format (i.e. large print, Braille) upon request. Hearing impaired <br />individuals using a T'FY may cai[ the Minnesota Relay Service <br />at 1-800-627-3529 and ask to place a call to 651-639-4000. <br /> <br />-118- <br /> <br />information when received by the Board, and will be used to <br />determine your compliance with Minnesota statutes and rules <br />· governin~ lawfql-gambling'a, ctivi~ies'. <br /> ' P~ge' 1 "of 2 <br /> 1/99 <br /> <br />I <br />I <br /> <br /> <br />