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["IMPORTANT:  WV Code Chapter 5A, Article 10 vests in the Real Estate Division the sole authority to lease or acquire all space required by a state agency, except as specifically exempted.  Real Estate Division regulations require that this form be completed prior to an agency leasing, renewing a lease, or acquiring space. ALL FIELDS MUST BE COMPLETED."]
[]
[]
[]
["TRANSACTION TYPE:"]
[null,null,null,"Please enter the transaction type (New Space, Lease Renewal, Cancellation, Non-Renewal, Expansion or Contraction, etc.)"]
[]
["DATE:",null,null,null,null,null,null,"REQUISTION FOR LEASED SPACE",null,null,null,null,null,null,null,null,null,null,"LEASE #:"]
[]
[]
[]
[]
["AGENCY CONTACT INFORMATION:",null,null,null,null,null,null,null,null,null,null,null,"Agency Contact: "]
["Agency:",null,null,null,null,null,null,null,null,null,null,null,"Contact Title:"]
["Address:",null,null,null,null,null,null,null,null,null,null,null,"Department:"]
["City/State/Zip:",null,null,null,null,null,null,null,null,null,null,null,"Phone Number:"]
["Fax Number:",null,null,null,null,null,null,null,null,null,null,null,"E-mail Address:"]
[]
["DESCRIPTION OF DESIRED OR CURRENT LEASED SPACE:"]
[]
[]
[]
[]
[]
[]
["RENT AND TERM:",null,null,null,null,null,null,null,null,null,null,null,"SERVICES PROVIDED:",null,null,null,null,null,"PAID BY:"]
[]
["Current Rent:",null,null,null,null,null,null,"(per sq. foot)",null,null,null,null,"Water/Sewer",null,null,null,null,null,"Lessor",null,"Tenant",null,"N/A"]
[null,null,null,null,null,null,null,"(monthly)",null,null,null,null,"Electricity",null,null,null,null,null,"Lessor",null,"Tenant",null,"N/A"]
[null,null,null,null,null,null,null,null,null,null,null,null,"Natural Gas",null,null,null,null,null,"Lessor",null,"Tenant",null,"N/A"]
["Current Term:",null,null,null,null,null,null,"years",null,null,null,null,"Trash Removal",null,null,null,null,null,"Lessor",null,"Tenant",null,"N/A"]
["Desired New Term:",null,null,null,null,null,null,"years*",null,null,null,null,"Snow Removal",null,null,null,null,null,"Lessor",null,"Tenant",null,"N/A"]
[null,null,null,null,null,null,null,"Other (specify)",null,null,null,null,"Custodial Service/Supplies",null,null,null,null,null,"Lessor",null,"Tenant",null,"N/A"]
["*Maximum allowable 40 years",null,null,null,null,null,null,null,null,null,null,null,null,"# Parking Spaces",null,null,null,null,"Lessor",null,"Tenant",null,"N/A"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,"Service Changes:",null,null,null,null,null,"Yes",null,"No"]
[]
["Head Count: ",null,null,null,null,null,null,null,null,null,null,null,"If Yes, What Changes:  "]
[]
[]
["LESSOR (Property Owner) DATA:",null,null,null,null,null,null,null,null,null,null,null,"Registered in wvOASIS:",null,null,null,null,null,"Yes",null,"No"]
["Lessor Name:    ",null,null,null,null,null,null,null,null,null,null,null,"Contact Person:"]
["Address:",null,null,null,null,null,null,null,null,null,null,null,"Phone Number:"]
["City:",null,null,null,null,null,null,null,null,null,null,null,"Fax Number:"]
["State:",null,null,null,null,null,"Zip:  ",null,null,null,null,null,"E-mail Address:"]
[]
["LESSOR ORGANIZATIONAL INFORMATION: "]
[]
["Lessor Business Type: ",null,null,null,null,null,null,null,"State Incorporated in:"]
[null,null,null,null,null,null,null,null,"Name of Signatory:"]
["Corporation, Limited Liability Company, Etc.*",null,null,null,null,null,null,null,"Title of Signatory:"]
["Board, Commission, Authority, City Council **",null,null,null,null,null,null,null,"Name of Signatory:"]
[null,null,null,null,null,null,null,null,"Title of Signatory:"]
[]
["ISSUES/CONCERNS:",null,null,"Please state any changes, issues, or concerns with regards to the property, Lessor, maintenance, etc."]
[]
[]
["*Note:  Persons signing for a corporation who hold positions other than President or Vice-President must have written authorization from said President or Vice-President granting them signature authority "]
["**Note:  Approved meeting minutes from the board, city council, county commission, authority, etc. are required."]
["I certify:  1) that the cost of rent and other expenses incurred for the space described herein shall be the full responsibility of this agency; 2) this space is required for "]
["the proper function of this agency; and, 3) that satisfactory space is not available on grounds or in buildings or facilities currently owned or leased by the State."]
["By:",null,null,null,null,null,null,null,"Title:",null,null,null,null,null,null,null,null,null,null,"Date:"]

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