Exhibit E - GSA Form 1217 Lessor Annual Cost

GSA Public Buildings Service

EXHIBIT E

LESSOR’S ANNUAL COST STATEMENT

1. REQUEST FOR LEASE PROPOSALS NUMBER 36C248-25-R-0031

2. STATEMENT DATE

3. RENTABLE AREA (SQ. FT.)

3A. ENTIRE BUILDING

4. BUILDING NAME

BUILDING STREET

CITY

STATE

3B. LEASED BY

GOV'T

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

GOV'T-LEASED AREA

GOV’T USE ONLY

(a)
(b)
(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

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

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:

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

34A. (Check one)

34B.

34C.

34D.

35A. (Check one)

35B.

35C.

35D.

NAME

SIGNATURE

DATE

GSA FORM 1217 1994-electronic ver.