Form GSA Form 1217 GSA Form 1217 Lessor's Annual Cost Statement

LESSOR'S ANNUAL COST STATEMENT 1. SOLICITATION FOR OFFERS 2. STATEMENT DATE OMB Control Number:
3090-00XX
IMPORTANT - Read attached "Instructions"
on the back of this form.
3A. ENTIRE
3B. LEASED BY
3. RENTAL AREA
BUILDING
GOVERNMENT
Expiration Date:
GENERAL SERVICES ADMINISTRATION (SQUARE FEET)
PUBLIC BUILDINGS SERVICE
xx/xx/2011
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) GOV'T-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 (Including elevators)
12, REPLACEMENT OF BLUBS, 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 11 above)
19. SYSTEM MAINTENANCE AND REPAIR

F. ELEVATORS
20. SALARIES (Operators, starters, etc.)
21. SYSTEM MAINTENANCE AND REPAIR

G. MISCELLANEOUS (To the extent not included above)
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

GENERAL SERVICES ADMINISTRATION

GSA 1217 (REV. 1/2011)

SECTION II - ESTIMATED ANNUAL COST OF OWNERSHIP EXCLUSIVE OF CAPITAL CHARGES
LESSOR'S ANNUAL COST FOR

SERVICES AND UTILITIES

(a)ENTIRE BUILDING (b) GOV'T-LEASED AREA

FOR
GOVERNMENT
USE ONLY

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 cost of services,
utilities and ownership.

34. SIGNATURE OF

TYPED NAME AND TITLE

OWNER

LEGAL AGENT

SIGNATURE

DATE

34A.

34B.

34C.

35A.

35B.

35C.

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
1. Enter the Government Lease or Solicitation for
Offers number, if available.
2. Enter the date that your statement was prepared
and signed.
3A. 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 service areas typically include rest
rooms, janitor rooms, telephone closets,
electrical closets, and mechanical rooms. The
rentable space generally does not include
vertical building penetrations and their enclosing
walls, such as stairs, elevator shafts, and vertical
ducts.
3B. 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.

SECTION I
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 Solicitation for Offers
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.

SECTION II
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.
30. Enter the annual cost of wages, materials,
and outside services used in repairs and
maintenance cost not included in Section 1
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.
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 expenses.
34. - 35. Complete Lessor Certification.

GSA 1217 (REV. 1/2011) BACK