GSA1217

Lessor's Annual Cost Statement

Agency
GSA
Revision
Rev. 11/2016
Fillable fields
105
Pages
3
Official source
GSA form page
Checked
October 20, 2026
Fill GSA1217 online
Page 1 of form GSA1217

GSA Form 1217: Lessor's Annual Cost Statement

GSA Form 1217, Lessor's Annual Cost Statement, is a General Services Administration form, GSA 1217 (REV. 11/2016), with OMB Control Number 3090-0086 and an expiration date of 2/28/2029. GSA hosts it in its forms library, and GSA's page lists the authority as APD 2800.12B.

The lessor enters estimated annual costs for the entire building in column (a) and for the area leased by the Government in column (b). Section I covers services and utilities the lessor furnishes as part of the rental consideration: cleaning, heating, electrical, plumbing, air conditioning, elevators and miscellaneous items. Section II covers the annual cost of ownership exclusive of capital charges, such as real estate taxes, insurance and management.

The instructions say it is GSA's established policy to enter into leases only at rental charges consistent with prevailing scales in the community. GSA estimates 2 hours to read the instructions, gather the facts and answer the questions. You can fill it out free in your browser on this page and download the result without an account.

Top of page 1 of GSA Form 1217: Lessor's Annual Cost Statement, as printed by GSA

What's on GSA Form 1217

Items 1 to 4: lease and building

The RLP or lease number, the statement date, the rental area in square feet for the entire building (3A) and for the area leased by the Government (3B), and the building name and address.

Section I, A to C: cleaning, heating, electrical

Items 5 to 14: cleaning salaries, supplies and contract services; heating salaries, fuel type (oil, gas, coal or electric) and system repair; current for light and power, bulb replacement, power for special equipment and electrical repair.

Section I, D to F: plumbing, cooling, elevators

Items 15 to 21: water including sewage charges, plumbing supplies and repair, air conditioning utilities and repair, and elevator salaries and repair.

Section I, G: miscellaneous

Items 22 to 27: building engineer or manager, security, Social Security tax and workperson's compensation insurance, lawn and landscaping, other costs explained on a separate sheet, and a total.

Section II: cost of ownership

Items 28 to 33: real estate taxes, insurance, building maintenance and reserves for replacement, lease commission, management, and a total, exclusive of capital charges.

Items 34 and 35: certification

The lessor certifies that the amounts in columns (a) and (b) are a best estimate of the annual costs of services, utilities and ownership, and signs as Owner or Legal Agent.

Items 1 to 35 run over two pages, followed by a page of instructions.

How to complete GSA Form 1217

  1. 1

    Enter the lease details

    Items 1 and 2 take the lease or RLP number, if available, and the date the statement was prepared and signed. Item 4 identifies the property by name and address.

  2. 2

    Compute the rentable area

    The instructions say 3A is measured to the inside finish of permanent outer building walls and corridor walls, and 3B only to the center of partitions separating the Government's area from other rentable areas.

  3. 3

    Check what the lease covers

    The instructions say to review the RLP and/or the proposed lease to identify the services and utilities furnished by the lessor as part of the rental consideration.

  4. 4

    Enter costs in both columns

    The instructions say to enter a best cost estimate, or the actual cost from the previous year, in column (a) for the entire building and column (b) for the Government's area. A category total may replace its items if records are not kept item by item.

  5. 5

    Complete Section II in every case

    The instructions say items 28 to 32 are completed whether or not Section I applies. Item 32 includes administrative expenses but not financial charges such as income or corporate taxes.

  6. 6

    Explain and sign

    The form asks for a separate sheet to explain any service not furnished throughout the building, any that costs more in the Government's space, and Other costs in item 26. Then the lessor signs the certification.

These steps follow the instructions page of the form.

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Submission, time and authority

Where it goes

The PDF gives no filing address for the completed statement. It refers to the Request for Lease Proposals and the proposed lease the statement goes with.

Time to complete

GSA estimates it will take 2 hours to read the instructions, gather the facts and answer the questions.

Burden comments only

The form says to send only comments on the time estimate to U.S. General Services Administration, Regulatory Secretariat Division (MVCB), 1800 F Street, NW, Washington, DC 20405.

OMB control number

OMB Control Number 3090-0086, expiration date 2/28/2029. The form cites 44 U.S.C. § 3507 and says the questions need not be answered unless a valid OMB control number is displayed.

Authority

GSA's page lists APD 2800.12B as the authority or regulation and a current revision date of 11/2016.

Related forms

Who fills out GSA Form 1217?

  • The lessor

    The building owner or legal agent offering or leasing space to the Government enters the cost estimates. Item 34 has check boxes for Owner and Legal Agent.

  • Lessors answering a Request for Lease Proposals

    Item 1 asks for the Government lease or Request for Lease Proposals (RLP) number, if available. The instructions point to the RLP and the proposed lease to see which services the lessor furnishes.

  • The signers of the certification

    Lines 34A to 34C and 35A to 35C hold a typed name and title, a signature and a date for the lessor's certification.

  • The Government

    A FOR GOVERNMENT USE ONLY column runs beside Section I. The instructions say items 28 to 32 will be useful in the Government's determination of the fair market value of the space to be rented.

The form is completed and certified by the lessor. A separate column is kept for the Government.

Official sources and the blank

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Questions about Form GSA1217

Who completes GSA Form 1217?

The lessor. The certification in item 34 is signed by the Owner or a Legal Agent, with a typed name and title, a signature and a date.

What is the difference between columns (a) and (b)?

Column (a) is the lessor's annual cost for the entire building. Column (b) is the cost for the area leased by, or to be rented to, the Government.

Can last year's actual costs be used?

The instructions say to enter your best cost estimate, or the actual cost from the previous year, for each service and utility.

What if records are not kept item by item?

The instructions say the total for a major category, A through F, may be entered under the category heading in columns (a) and (b) instead of the specific items.

Is Section II needed if Section I does not apply?

The instructions say items 28 through 32 shall be completed irrespective of whether Section I is applicable, because they will be useful in the Government's determination of the fair market value of the space.

What goes in item 32, Management?

The instructions say to include administrative expenses such as agency fees, legal fees, auditing and advertising, and not financial charges such as income or corporate taxes or organization expense.

How long does GSA Form 1217 take?

GSA estimates 2 hours to read the instructions, gather the facts and answer the questions.