Exhibit 3 - 1217 Lessor Annual Statement.pdf

PDF 853 KB Posted

Attached to
US Government Seeks to Lease Space in Sheridan, WY (RLP Package)
Solicitation number
9WY2086
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GSA Public Buildings Service

Page 1 of 2 GSA FORM 1217 1994-electronic ver.

LESSOR’S ANNUAL COST STATEMENT

1. SOLICITATION FOR OFFERS 2. STATEMENT DATE

3. RENTABLE AREA (SQ. FT.) 3A. ENTIRE BUILDING 3B. LEASED BY

GOV'T

4. BUILDING NAME BUILDING STREET

CITY STATE ZIP CODE

SECTION I - ESTIMATED ANNUAL COST OF SERVICES & UTILITIES FURNISHED BY LESSOR AS PART OF RENTAL

CONSIDERATION

SERVICES AND UTILITIES LESSOR'S ANNUAL COST FOR:

ENTIRE BUILDING

(a)

GOV'T-LEASED AREA

(b)

GOV’T USE ONLY

(c)

A. CLEANING, JANITOR AND/OR CHAR SERVICE

5. SALARIES

6. SUPPLIES (wax, cleansers, cloths, etc.)

7. CONTRACT SERVICES (Window washing, waste and snow removal)

B. HEATING

8. SALARIES

9. FUEL ("x" one)

___OIL ___GAS ___COAL ___ELECTRIC

10. SYSTEM MAINTENANCE AND REPAIR

C. ELECTRICAL

11. CURRENT FOR LIGHT AND POWER (Including elevators)

12. REPLACEMENT OF BULBS, TUBES, STARTERS

13. POWER FOR SPECIAL EQUIPMENT

14. SYSTEM MAINTENANCE AND REPAIR (Ballasts, fixtures, etc.)

D. PLUMBING

15. WATER (For all purposes) (Include sewage charges)

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

17. SYSTEM MAINTENANCE AND REPAIR

E. AIR CONDITIONING

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

19. SYSTEM MAINTENANCE AND REPAIR

EXHIBIT 3

Page 2 of 2 GSA FORM 1217 1994-electronic ver.

F. ELEVATORS

20. SALARIES (Operators, starters, etc.)

21. SYSTEM MAINTENANCE AND REPAIR

G. MISCELLANEOUS

22. BUILDING ENGINEER AND/OR MANAGER

23. SECURITY (Watchmen, guards, not janitors)

24. SOCIAL SECURITY TAX AND WORKMEN'S

COMPENSATION INSURANCE

25. LAWN AND LANDSCAPING MAINTENANCE

26. OTHER (Explain on separate sheet)

27. TOTAL $0.00 $0.00 $0.00

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

28. REAL ESTATE TAXES

29. INSURANCE (Hazard, liability, etc.)

30. BUILDING MAINTENANCE AND RESERVES FOR

REPLACEMENT

31. LEASE COMMISSION

32. MANAGEMENT

33. TOTAL $0.00 $0.00 $0.00

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.

TITLE NAME SIGNATURE DATE

34A. (Check one)

34B. 34C. 34D.

35A. (Check one)

35B. 35C. 35D.

EXHIBIT 3

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