Exhibit G - Form 1217 - Lessor s Annual Cost Statement (Nov. 2016)

LESSOR'S ANNUAL COST STATEMENT

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OMB Control Number: 3090-0086
Expiration Date: 2/28/2029

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1. Request for Lease Proposals (RLP)

2. Statement Date

3. Rental Area (Square Feet)

3A. Entire Building

3B. Leased by Government

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

LESSOR'S ANNUAL COST FOR

SERVICES AND UTILITIES

(a) Entire Building

(b) Government-Leased Area

FOR GOVERNMENT

USE ONLY

A. CLEANING, JANITOR AND/OR CHAR SERVICE

5. Salaries

6. Supplies (Wax, cleaners, 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

12. Replacement of Bulbs, Tires, 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

GENERAL SERVICES ADMINISTRATION

GSA 1217 (REV. 11/2016)

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

22. Building Engineer and/or Manager

23. Security (Watchperson, guards, not janitors)

24. Social Security Tax and Workperson'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.)