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Minnesota Lawful Gambling <br />Lease for Puli-Tab, Paddlewheel, Tipboard, <br /> <br />and/or Raffle Activity <br /> <br />,- LG221 <br /> <br /> Name or' Legal Owner of Premises Street Address City <br /> <br /> Name ot Lessor Street Address <br /> (If same as legal owner, write in "S~E") <br /> <br /> Name of Leased ~remises Street Address <br /> <br /> Name of Lessee (name of organization leasing the premises) <br /> <br />Rent Information <br /> <br /> /Jcado cefz Zip Daytime Phone <br /> City Zip Daytime Phbn'e <br /> <br /> City . / Zip Daytime Phone <br /> <br />75'..~0 /,/~o:1 Io wu. Loe,fF,~q~Fc? ( 0/,)-" ) <br /> GCB license no. of organization Daytime Phone <br /> <br /> .! <br /> <br />· Total ;'ent cannot exceed $1,000 per month for all <br /> non-bingo activity for this premises. <br /> <br />· For bingo activity, use lease form LG222. <br /> <br />° For pull-tab dispensing machines, use lease form <br /> LG223. <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 $ <br />(If no rent is to be paid, Indicate <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 />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 />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 />square feet. <br />square fe~t. <br />square feet. <br /> <br />Lawful Gambling Activity <br /> <br /> "~ Tipboards <br /> <br />I Type of gambling activity that will be conducted at this gambling premises. Check all that apply. <br /> <br /> ~ IPaddlewheels '7~ Pull;Tabs "~ Raffles <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 /> <br />andlessee. <br /> <br />If this is an amended lease showing changes occurring dur- <br />lng 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 <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 remain§ <br />private. <br /> I <br /> Page 1 of 2 <br /> Rev. 8197 <br /> <br /> <br />