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I <br />I <br /> <br />Minnesota Lawful Gambling <br />Lease for Puli-Tab, Paddlewheel, Tipboard, and/or Raffle Activity -LG221 <br /> <br />I <br />I <br />I <br /> <br />Name of Legal Owner of Premises Street Address City Zip 5..~ .l~aytime~ Phone <br /> <br />Name of LeSsor StreetAddress City Zip Daytime Phone <br />(If same as legal owner, wdte in "SAME") · <br /> <br /> Zip Daytime Phone <br />Name of Leased Premises Street Address City . <br /> <br />Name of Lessee (n~lme of organization leasing the premises) I GCB license nl, ~f organization Daytime Phon~ <br /> <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 />· Fo~ bingo activity, use lease form LG222. <br /> <br />· For pull-tab dispensing machines, use lease form <br /> LG223.. <br /> <br />Sketch and Dimensions of Leased Area <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 />IRent to be paid'per month $ ' <br /> (If no rent is to be paid, indicate -0-) ~'/~)'~'~ <br /> <br />I <br />! <br />I <br />I <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 />leased area(s), and (2) the dimensions. <br /> <br />Dimensions <br />The leased areas are: <br /> <br />Storage <br />Storage <br /> <br />feet by J I~. feet for a total of <br />feet by feet for a total of <br />feet by feet for a total of <br />feet by feet for a total of <br />feet by feet for a total of <br /> Combined total <br /> <br />square feet. <br />square feet. <br />square feet. <br />square feet. <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 /> )~ 'Paddlewheels · ~"PulI-Tabs ,'~:' Raffles , ,,~ Tipboards <br /> <br />Term of Lease Amended Lease Only <br /> <br />The term of this lease agreement will be concurrent with the <br />premises permit issued by the Gambling Control Board, <br />unless terminated sooner by mutual consent of the lessor <br />and lessee. <br /> <br />If this is an amended lease showing changes occurring dur- <br />ing the term of the current premises permit, write in the <br />date that the changes will be effective __/__/__ <br />Both parties that signed the lease must initial and date ali <br />changes. <br /> <br />Questions on this form should be directed to the Licensing <br />Section of the Gambling Control Board at (612) 639-4000. <br />This publication will be made available in alternative format <br />(i.e. large print, Braille) upon request. Hearing impaired <br />individuals using a TTY may call the Minnesota Relay Service <br />at 1-800-627-3529 and ask to place a call to (612) 639-4000. <br /> <br />The information requested on this form will be used by the <br />Gambling Control Board (Board) to determine your compliance <br />with Minnesota statutes and rules governing lawful gambling <br />activities. All of the information that you supply on this form <br />will become public information when received by the Board <br />except, if required, your Social Secudty number, which remains <br />private. <br /> Page 1 of 2 <br /> Rev. 8/97 <br /> <br /> <br />