Certification of Compliance

CERTIFICATION OF COMPLIANCE

By signing a Certification of Compliance, the agency head attests that all leasing criteria have been met. An original of the Certification of Compliance is to be submitted with all new, renewal or modification lease transactions except for cancellations, change of ownership or change of payee.

INSTRUCTIONS FOR COMPLETING THE CERTIFICATION OF COMPLIANCE

(1) DEPARTMENT Enter agency name.

(2) DIVISION Enter the division name, region or district.

(3) BUREAU Enter the bureau name if applicable.

(4) LEASE NUMBER Enter the lease number assigned by DMS on the RSN.

(5) PRIOR APPROVAL Was RSN approved, check appropriate selection.

(6) ADDITIONAL COVENANTS Check appropriate selection.

(7) SPACE AVAILABLE Check appropriate selection.

(8) SECTION 255.25(8) Check appropriate selection.

(9) LEASE AGREEMENT Check if Standard Lease Agreement is executed and attached.

(10) SPACE MEASUREMENT Check appropriate selection.

(11) RENTAL RATE Check appropriate selection (Zone Rates).

(12) DISCLOSURE STATEMENT Check appropriate selection.

(13) BIDS Check appropriate selection.

(14) COMPETITIVE QUOTES Check appropriate selection.

(15) CONSTRUCTION Check appropriate selection.

(16) FIRE MARSHAL Check appropriate selection denoting State Fire Marshal approval.

(17) FIRE MARSHAL Compliance with the Fire Safety Standards.

(18) FLORIDA ENERGY MODELING Check appropriate selection.

PROGRAM (FEMP)

(19) SECURITY Check appropriate selection.

(20) CONFLICT OF INTEREST Check appropriate selection.

(21) PUBLIC ENTITY CRIME Check appropriate selection.

(22) ZONE Check appropriate selection, denoting compliance of local real estate zoning codes

(23) REMARKS Any responses that need further explanation can be detailed here.

(24) SIGNED/TITLE Signature & Title of authorized agency official and date signed.

STATE OF FLORIDA

DEPARTMENT OF MANAGEMENT SERVICES

CERTIFICATION OF COMPLIANCE

TO: Department of Management Services

Division of Facilities Management

Bureau of Real Property Management

FROM: Department of: (1)

Division of: (2)

Bureau of: (3)

RE: Lease Number: _____(4)______

The undersigned hereby certifies that the lease is in the best interest of the State and in compliance with all applicable leasing criteria, as follows:

1. / Prior Approval of Space Need has been obtained and utilization of the DMS Tenant Representative. (5) / YES / NO
2. / Any changes or additional covenants to the lease document have received prior approval for use by the Division of Facilities Management (6) / YES /

NO

3. / The Department of Management Services’ Space Available Report was utilized in the acquisition of this space. (7) / YES / NO
4. / This lease is in compliance with Section 255.25(8), Florida Statutes, in that space totaling more than 4,999 square feet has not been acquired in the same facility or complex within the previous twelve months, based on the entered into date of the lease document. (8) / YES / NO
5. / Standard Lease Agreement or other document has been properly executed by all parties thereto, and if for less than 5,000 square feet, has been approved by this Agency’s Attorney as to form and legality. (9) / Attached______
6. / Space has been measured or otherwise verified by this Agency, and the net rentable square footage shown is in accordance with the Department of Management Services’ Standard Method of Space Measurement. Floor plan is attached or on file.
(10) / Attached______
ON FILE:
DMS:_____AGENCY_____
7. / Rental rate is within the guidelines established by the Department of Management Services. (11) /

YES

/ NO
8. / Statement of Disclosure is attached.
(12) /

FM 4114

/ Statement
9. / Competitive proposals were received for leased space of 5,000 square feet or more, and award was made to the lowest and best responsive bidder. Copy of specifications and synopsis of all proposals received are attached. (13) / YES /

NO______

N/A _____
9a. / Three or more competitive quotes were received for this lease, and lease was entered into for the lowest and best quote. A copy of all quotes received is attached.
(14) / YES / NO______
N/A______
10. / Construction or renovations are required for this lease.
(15) / YES / NO
10a. / If yes, the proposed construction or renovation plans comply with Fire Safety Uniform Standards of the Division of State Fire Marshal, and approval received there from. (16) /

Attached

Pending

11. / Leased space is in compliance with the Fire Safety Standards of the Division of State Fire Marshal. State Fire Marshal or local Fire Department fire safety inspection report attached. (17) /

YES

NO

FM 4113 (R05/04)

12. / If applicable, a Florida Energy Modeling Program (FEMP) was performed by the State. Copy attached (18) /

Attached

/ N/A
13. / Provisions for security of leased space have been accomplished.
(19) / YES / NO
14. / Required attestations relative to conflict of interest have been secured in compliance with Section 255.25(11), Florida Statutes. (20) / YES / NO
15. / Statement required by Section 287.133, Florida Statutes, which addresses Public Entity Crime was obtained, and agency is in compliance with all provisions of said statute. (21) / YES / NO______
N/A______
16. / Site is zoned allowing usage proposed. (22) / YES / NO

Remarks:______(23)______

______

Signed______(24)______Date______Title______

FM 4113 (R05/04)

DISCLOSURE STATEMENT

The Disclosure Statement is required by Chapter 255, Florida Statutes and must be provided to the Department of Management Services with each lease action. A Disclosure Update Statement may be used if there are no changes on the Disclosure Statement on file.

INSTRUCTIONS FOR DISCLOSURE STATEMENT

(1) LEASE NO. Enter the lease number assigned by DMS to this lease.

(2) CHECK ONE Check the appropriate description.

(3) NAME OF ENTITY Enter the name of person or entity that owns facility.

(4) NAME OF FACILITY Enter the name of the building or facility that will be occupied by this lease.

(5) STREET ADDRESS Enter the street address of the building or facility to be occupied.

(6) CITY Enter city in which this building or facility is located.

(7) COUNTY Enter county in which this building or facility is located.

(8) ZIP Enter the zip code for this building or facility.

(9) NET USABLE S.F. IN BUILDING Enter the total square feet that is rentable in this building.

(10) F.I.N./S.S.N.: Enter the F.I.N. of the entity holding title or if an individual enter their social security number.

(11) PUBLICLY OWNED FACILITIES Check appropriate response. If publicly owned skip to signature portion.

(12) PUBLIC CORPORATION Mark appropriate response as to public corporation.

If the corporation is represented on the stock exchange or is registered to sell stock to the general public, don not fill in next section, go to signature block.

(13) Fill in the following information on every individual or entity who owns 4% or more interest in this property.

(13a.) NAME Enter persons or entity’s name.

(13b.) HOME ADDRESS Enter persons home address or entity’s business address.

(13c.) PRINCIPAL OCCUPATION Enter persons primary occupation (omit for entity).

(13d.) OCCUPATIONAL ADDRESS Enter business or occupational address.

(13e.) PERCENT OF INTEREST Enter this persons or entity’s % ownership.

REPEAT AS MANY TIMES AS NECESSARY FOR ALL PERSONS WHO HOLD 4% OR MORE INTEREST IN THIS PROPERTY. THIS MUST BE FILLED OUT ON PUBLIC EMPLOYEES OR OFFICIALS NO MATTER HOW MUCH INTEREST THEY HAVE IN THE PROPERTY.

(14) EQUITY OF ALL OTHERS Enter the percentage of all persons not listed in (14). This added to the total of all persons listed, must equal 100%.

(15) NAME OF OFFICIAL OR EMPLOYEE If a public official, agent, or employee holds any interest in this property, enter that person’s name.

(16) NAME OF PUBLIC AGENCY Enter the public agency where the person is employed.

(17) POSITION HELD Enter the title or position held by this person.

(18) IF OWNER IS INDIVIDUAL Enter owner(s) name, this must match the name(s) on the lease.

(19) MANUAL SIGNATURE Have the persons listed in (19) sign on the corresponding line.

(20) DATE SIGNED The date the form is signed.

(21) IF OWNER(S) IS CORPORATION, ETC. Enter the name of the corporation, partnership trust fund, etc.

(22) CORPORATE Print or type name of person authorized to sign for entity and affix seal. If they do not have a seal, they can draw a circle with a quarter and write the word seal in the circle or attach a statement stating they have no seal.

(23) SIGNATURE The authorized person named in (23) needs to sign here.

(24) TITLE Enter the persons title or position with the entity named in (23).

(25) DATE SIGNED Person signing in (24) needs to enter date they signed statement.

(26) ADDITIONAL PAGE This is a supplement to page 1 and is for additional owners.

STATE OF FLORIDA

DEPARTMENT OF MANAGEMENT SERVICES

DISCLOSURE STATEMENT

Lease No: (1)

Authority: Paragraphs 255.249(4)(h)(i), 255.01 F.S.

Check One: (2) Privately Owned Entity Holding Title Publicly Owned

Name of Entity: (3)

Name of Facility: (4)

Facility Location:: (5)

City: (6) County: (7) Zip: (8)

Total Net Rentable Square Footage in Building (9)

Federal Identification No. (F.I.N. or S.S.N.) (10)

PUBLICLY OWNED FACILITIES COMPLETE THIS AND SIGNATURE PORTION ONLY:

IS THIS FACILITY FINANCED WITH LOCAL GOVERNMENT OBLIGATIONS OF ANY TYPE? YES NO (11)

This is to certify that the following individual(s) or entity holds 4% or more interest and/or the following public official(s), agent(s) or employee(s) holds any interest in the property or in the entity holding title to the property being leased to the State.

This is to certify that all beneficial interest is represented by stock in a corporation registered with the Securities and Exchange Commission or is registered pursuant to Chapter 517, Florida Statutes, which stock is for sale to the general public. Yes No (12)

If entity is a Corporation (not registered with the Securities and Exchange Commission), provide information for any individual holding 4% or more interest in the Corporation. If no one holds more than 4% then so state. (13)

Name: (13a)

Home Address: (13b)

Principal Occupation: (13c)

Occupational Address: (13d)

Percent of Interest: (13e)

Name:

Home Address:

Principal Occupation:

Occupational Address:

Percent of Interest:

(Attach additional pages if necessary)

FM 4114 (R05/04) 1 of 3

Lease No.:

The equity of all others holding interest in the above named property totals: (14) .

If a public official, agent or employee provide:

Name of individual: (15)

Name of public agency: (16)

Position held: (17)

If Owner(s) is an Individual:

(18) (19)

(Print or Type) (Manual Signature)

(18) (19)

(Print or Type) (Manual Signature)

Date Signed: (20)

If Owner(s) is Corporation,

Partnership, Trust, etc: (21)

Print or Type Name Corporation, Partnership, Trust,

(22) etc.

CORPORATE

SEAL

(22)

Authorized Signature

This is to certify that I, (23) , as (24) ,

(Print or Type Name (Print or Type Title)

am authorized to sign for the required information thereon.

Date Signed: (25)

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Disclosure Statement

Additional Page Lease No.:

Name (26)

Home Address:

Principal Occupation:

Occupational Address:

Percent of Interest:

Name

Home Address:

Principal Occupation:

Occupational Address:

Percent of Interest:

Name

Home Address:

Principal Occupation:

Occupational Address:

Percent of Interest:

Name

Home Address:

Principal Occupation:

Occupational Address:

Percent of Interest:

Name

Home Address:

Principal Occupation:

Occupational Address:

Percent of Interest:

FM 4114 (R05/04) 3 of 3

CERTIFICATION OF EXEMPTION

INSTRUCTIONS FOR COMPLETING CERTIFICATION OF EXEMPTION

(1) DEPARTMENT: Enter Department or Agency name.

(2) DIVISION: Enter Division, Region or District.

(3) BUREAU: Enter Bureau if applicable.

(4) LEASE NO.: Enter lease number assigned by DMS.

(5) LOCATION: Enter city where facility is located.

(6) PROGRAM: Enter name of Program to be housed in facility.

(7) FUNCTION: Provide detailed description of function and purpose of Program.

(8) DATE: Enter date signed.

(9) AGENCY HEAD: Agency Head or authorized signature.

(10) TITLE: Title of person signing certificate.

STATE OF FLORIDA

DEPARTMENT OF MANAGEMENT SERVICES

CERTIFICATION OF EXEMPTION

FROM COMPETITIVE BIDS

FROM: Department of: (1)

Division of: (2)

Bureau of: (3)

RE: Lease No.: (4)

Location: (5)

This is to certify that the above referenced lease is for the purpose of providing care and living space for persons. Specifically, this space will be used for a

(6)

Name of Program

which function is to: (describe function and purpose of program).

(7)

(8) (9)

Date Agency Head

(10)

Title

FM 4115 (R 05/04)

PLEASE NOTE YOUR COMMENTS AND SUGGESTIONS AND SEND THEM TO DMS

CHAPTER 3

Lisa Lehman

Department of Management Services

Bureau of Property Management

Building 4030, Suite 315

4050 Esplanade Way

Tallahassee, FL 32399-0950