EXHIBIT G - GSA1217-16_FILLABLE-form.pdf

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LESSOR'S ANNUAL COST STATEMENT

Important - Read attached "Instructions" OMB Control Number: 3090-0086 Expiration Date: 11/30/2019

4. Building Name and Address (Number, Street, City, State, and Zip Code) SECTION I - ESTIMATED ANNUAL COST OF SERVICES AND UTILITIES FURNISHED BY LESSOR AS PART OF RENTAL CONSIDERATION

3. Rental Area (Square Feet)

SERVICES AND UTILITIES

A. CLEANING, JANITOR AND/OR CHAR SERVICE

B. HEATING

C. ELECTRICAL

D. PLUMBING

5. Salaries

FOR GOVERNMENT USE ONLY

LESSOR'S ANNUAL COST FOR

(a) Entire Building

8. Salaries

10. System Maintenance and Repair

11. Current for Light and Power

12. Replacement of Bulbs, Tires, Starters

13. Power for Special Equipment

9. Fuel ("X" one)

E. AIR CONDITIONING

F. ELEVATORS

GSA 1217 (REV. 11/2016)

6. Supplies (Wax, cleaners, cloths, etc.)

7. Contract Services (Window washing, waste and snow removal)

14. System Maintenance and Repair (Ballasts, Fixtures, etc.)

15. Water (For all purposes) (Include Sewage Charges)

16. Supplies (Soap, towels, tissues not in 6 above)

(b) Government-Leased Area 3A. Entire Building

2. Statement Date 3B. Leased by Government

1. Request for Lease Proposals (RLP) Paperwork Reduction Act Statement - This information collection meets the requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these questions unless we display a valid Office of Management and Budget (OMB) control number. The OMB control number for this collection is 3090-0086. We estimate that it will take 2 hours to read the instructions, gather the facts, and answer the questions. Send only comments relating to our time estimate, including suggestions for reducing this burden, or any other aspects of this collection of information to: U.S. General Services Administration, Regulatory Secretariat Division (M1V1CB), 1800 F Street, NW, Washington, DC 20405.

9. Fuel, select one of the following: Oil, Gas, Coal, Electric.

17. System Maintenance and Repair

18. Utilities (Include electricity, if not in C11)

19. System Maintenance and Repair

21. System Maintenance and Repair

GENERAL SERVICES ADMINISTRATION

20. Salaries (Operators, starters, etc.)

G. MISCELLANEOUS (To the extent not included on Page 1)

22. Building Engineer and/or Manager

23. Security (Watchperson, guards, not janitors)

25. Lawn and Landscaping Maintenance

26. Other (Explain on separate sheet)

27. TOTAL

34. Signature of:

28. Real Estate Taxes

29. Insurance (Hazard, Liability, etc.)

30. Building Maintenance and Reserves for Replacement

31. Lease Commission

32. Management

TYPED NAME AND TITLE

SIGNATURE

DATE

LESSOR'S CERTIFICATION - The amounts entered in Columns (a) and (b) represent my best estimate as to the annual costs of services, utilities, and ownership.

33. TOTAL

24. Social Security Tax and Workperson's Compensation Insurance

SECTION II - ESTIMATED ANNUAL COST OF OWNERSHIP EXCLUSIVE OF CAPITAL CHARGES

34. Signature of, select one of the following: Owner, Legal Agent.

GSA 1217 (REV. 11/2016) PAGE 2

INSTRUCTIONS

In acquiring space by lease, it is the established policy of GSA to enter into leases only at rental charges which are consistent with prevailing scales in the community for facilities.

ITEM NUMBER

SECTION I

ESTIMATED ANNUAL COST OF SERVICES AND UTILITIES

SECTION II

ESTIMATED ANNUAL COST OF OWNERSHIP EXCLUSIVE OF CAPITAL CHARGES

1. Enter the Government lease or Request for Lease Proposals (RLP) number, if available.

2. Enter the date that your statement was prepared and signed.

3. A. Enter in this block a computation of the rentable area (multiple tenancy basis) for the entire building. The rentable area shall be computed by measurement to the inside finish of permanent outer building walls to the inside finish of corridor walls (actual or proposed) or to other permanent partitions, or both. Rentable space is the area for which a tenant is charged rent. It is determined by the building owner and may vary by city or by building within the same city. The rentable space may include a share of building support/common areas such as elevator lobbies, building corridors, and floor service areas. Floor services areas typically include restrooms, janitor rooms, telephone closets, electrical closets, and mechanical rooms.

The rentable space generally does not include the vertical building penetrations and their enclosing walls, such as stairs, elevator shafts, and vertical ducts.

3. B. Enter in this block a computation of the rentable area to be rented to the Government. For this area, follow the procedure as outlined above, except that measurements are to be made only to the center of the partitions which separate the area to be rented by the Government from adjoining rented or rentable areas.

4. Identify the property by name and address.

5. - 26. The services and utilities listed in this section are required in most of our rented space whether furnished by the Government or the Lessor. Carefully review the Request for Lease Proposals (RLP) and/or the proposed lease to identify those services and utilities to be furnished by you as part of the rental consideration. Then enter your best cost estimate, or the actual cost from the previous year, for each of these services and utilities in column (a) for the entire building and in column (b) for the area to be rented to the Government. If any service or utility furnished for the space rented by the Government is not furnished throughout the building, or the cost of a service or utility furnished to the Government space exceeds the cost of the same service or utility furnished to other rented space, explain on a separate sheet. For convenience, each major category has been divided into separate items such as salaries and supplies so that they may be entered when applicable. However, in the event that your records are not maintained for each item contained in Section I, 5 through 26, the total for a major category (A through F) may be entered under the category heading in columns (a) and (b) in lieu of the specific items. System maintenance and repairs includes the annual cost of such items as oiling, inspecting, cleaning, regulating, and routine replacement costs.

Items 28 through 32 will be useful in the Government's determination of the fair market value of the space to be rented and shall be completed irrespective of whether Section I is applicable, as follows:

28. Include all applicable real estate taxes imposed upon the property.

29. Enter the annual cost of fire, liability, and other insurance carried on the real estate.

31. Enter any lease commission which you may be responsible for due to the Government leasing action.

32. Include administrative expenses such as agency fees, legal fees, auditing, and advertising. Do not include financial charges such as income or corporate taxes or organization expense.

34. - 35. Complete Lessor certification.

30. Enter the annual cost of wages, materials, and outside services used in repairs and maintenance of the building itself and all similar repairs and maintenance of the building itself and all similar repairs and maintenance costs not included in Section I above (Heating, Electrical, Plumbing, Air Conditioning, and Elevators). This includes major repairs and changes in the nature of a permanent improvement such as annual cost to replace relatively short-lived items such as boiler, compressors, elevators, and roof coverings.

GSA 1217 (REV. 11/2016) PAGE 3

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