State Form 202 - Request To Lease Space - Indiana Department Of Administration

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REQUEST TO LEASE SPACE

Please include any necessary attachments.

State Form 202 (R5 / 8-01)

After signature of your Agency Personnel, please forward to the

Indiana Department of Administration (IDOA), Leasing Section.

Type of request:

New Lease

Re-negotiation

Renewal

Amendment

A. CURRENT STATUS

Name of requesting agency / division

Current date (month, day, year)

Current address (number and street)

City, state, ZIP code

Current square footage

Current square foot lease rate

Does this rate include all utilities and services?

List additional expenses, if any:

Current Executive Order 99-04 category

Current expiration date

B. WHAT ARE YOU REQUESTING?

Desired square footage (If office space and in excess of 200 square feet per person guideline, attach a copy of a completed space justification formulary. If storage space, explain

how you determined the square footage needed.)

Desired term: (If in excess of 4 years, please attach a written request and justification.)

Projected annual additional rent costs: (utilities, janitorial, operating expenses, etc.)

Projected rental rate:

Projected one time expense for such items as systems furniture, telephone / data, tenant improvements to be paid for by your agency.

Projected move costs:

Projected Total cost:

Number of parking spaces needed:

Projected move date:

If you have already identified space, please attach an explanation as to how the property was identified, a 203 (Proposal for leasing space)

with all relevant information including whether it’s located in an area covered by Executive Order 99-04.

C. STAFFING INFORMATION