Note:
21 . 
ADDRESS OF PROPOSED PROPERTY 
25 . 
ADDRESS OF COMPARABLES 
A. 
B. 
C. 
31 · 
DESCRIBE IMPROVEMENTS TO BE MADE AT 
COST TO LESSEE 
33.
FOR WHAT PURPOSE IS THE SPACE REQUESTED?
22 . NAME OF LESSOR 
Revised 01/08 
23 . TELEPHONE 
24 . ADDRESS OF LESSOR (MAILING ADDRESS) 
26 · EXPLANATION (REFER TO ITEM NO.15 IF LOWEST RENTAL 
COST PROPERTY WAS NOT SELECTED GIVE REASON). 
32 . ACCOUNT NO. 
MED. NO 
TRANSFER VOUCHER NO. 
FUND SOURCE O FEDERAL 
O LOCAL 
34 . 
A). IS THE SPACE REQUIRED FOR MORE THAN TWO YEARS 
0 YES 
0 NO 
B). IF YES, STATE WHAT PLANS ARE BEING DEVELOPED BY YOUR AGENCY TO INCLUDE REQUESTED SPACE 
IN A GOVERNMENT OWNED FACIL!TY? 
35 . 
PROPERTY OFFICER OR PERSON PREPARING 
REQUEST 
SIGNATURE 
DATE 
DEPARTMENT OR AGENCY HEAD 
SIGNATURE 
DATE 
FOR DIVISION OF PROPERTY USE ONLY 
REVIEWING OFFICER 
DATE 
ACTION TAKEN 
O APPROVED 
0 DISAPPROVED 
APPROVING OFFICER 
DATE