SOLICITATION FOR OFFER
OUTPATIENT CLINIC, [INSERT LOCATION] SFO NO. V101-183R-XXX-XXX-XX
1. SOLICITATION FOR OFFERS
2. STATEMENT DATE
GENERAL SERVICES ADMINISTRATION
PUBLIC BUILDINGS SERVICE
3A. ENTIRE BUILDING
3B. LEASED BY GOV'T
LESSOR'S ANNUAL COST STATEMENT
3. RENTABLE AREA
(SQ. FT.)
IMPORTANT - Read attached "Instructions"
4.
BUILDING NAME AND ADDRESS (No., 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
FOR GOVERNMENT
SERVICES AND UTILITIES
USE ONLY
(a) ENTIRE BUILDING
(b) GOV'T-LEASED AREA
(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
OIL
GAS
COAL
ELECTRIC
("x" one)
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
(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
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
34.
SIGNATURE OF
OWNER
LEGAL AGENT
best estimate as to the annual costs of services, utilities and ownership.
TYPED NAME AND TITLE
SIGNATURE
DATE
34A.
34B.
34C.
35A.
35B.
35C.
GSA FORM 1217
GSA DC 65-2361
JUL 94
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