Exhibit G -Form 1217 Lessor Annual Cost.doc
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GSA Public Buildings Service Page 2 / 2
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
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. |
GSA FORM 1217 1994-electronic ver.
File details come from the government source that posted it. Updated .