Free 00202.pdf - Indiana

REQUEST TO LEASE SPACE
State Form 202 (R5 / 8-01)

Instructions: Please type or print all information. Please include any necessary attachments. 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
A. CURRENT STATUS

Amendment

Current date (month, day, year) Current address (number and street)

Name of requesting agency / division

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 expiration date

Current Executive Order 99-04 category

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
Number of full-time employees and classifications

Number of part-time employees and classifications

Number of any other type of employees working out of your office and their titles

D. APPROVAL
Agency Budget Date (month, day, year) Agency Leasing Date (month, day, year)

IDOA, Leasing:

Date (month, day, year)