New Jersey Ofce of the Attorney General
Division of Consumer Affairs
Legalized Games of Chance Control Commission
124 Halsey Street, P.O. Box 46000
Newark, N.J. 07101
(973) 273-8000
LGCCC Form 10-A
Statement of Landlord
(To be attached to each copy of the Bingo Application when premises are rented.)
____________________________________________________________________________________________________________
Name of the organization to conduct bingo
____________________________________________________________________________________________________________
Address Identication number
State of: __________________________________________________
County of: ________________________________________________
I, ________________________________________________ , being duly sworn on my oath depose and say that :
1. I am an authorized ofcer, namely the _________________________________________________ of _____________________
_________________________, in which the lessor of the premises to be rented, described in the annexed application.
2. The address of the lessor is: _________________________________________________________________________________
3. The rent to be charged and paid for the premises is $ ______________ for each occasion, including facilities, xtures and equipment.
4. (Complete the applicable clause)
A. The lessor is licensed to conduct bingo holding License No. ____________________ issued by the Governing Body of
_______________________________________________ .
B. The lessor is licensed as a rentor holding License No. ____________________ .
5. The rental to be charged and paid is reasonable and is not in excess of the rental ordinarily charged for the use of the premises other
than for games of chance.
6. I understand that no charge may be made on a percentage basis, or according to the number of persons attending, and that bingo
equipment may not be leased for a charge.
7. Attached to this statement there is a copy of the Lease Agreement.
____________________________________________________
Signature of Authorized Ofcer
Sworn and subscribed to before me this __________________
day of ____________________________ , ______________
Month Year
__________________________________________________
Name of Notary Public (please print)
__________________________________________________
Signature of Notary Public
Afx Seal Here
(Revised //1)
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