SCHEDULE 1 (Continued)
SCHEDULE 1 /ALL APPLICANTS
Except Transfer of CON
/ ESTIMATED PROJECT COSTSPage 1 of 2
Land Costs (Number of acres______)
1. / Purchase price of land / ______
2. / If donated land, fair market value / ______
3. / If converted from use other than hospital or nursing home,
include original cost plus improvements less depreciation / ______
4. / Environmental impact and other land use or traffic studies / ______
5. / Site survey, soil investigation report / ______
6. / Site preparation cost / ______
7. / Water, sewer and other utility systems / ______
8. / Landscaping / ______
9. / Roads and walks (site walks other than immediate building
and landscape hard surfaces / ______
10. / Other (must specify): ______/ ______
11. / TOTALLAND COST / ______
Building Costs
12a. / New construction (labor, materials, overhead, and profit) / ______
12b. / Renovation (labor, materials, overhead, and profit) / ______
13. / If donated building, fair market value / ______
14. / If converted from use other than hospital or nursing home,
include original cost plus improvements less depreciation / ______
15. / Architectural/engineering fees (fee _____ %) / ______
16. / Construction supervision / ______
17. / Plans and Construction fees / ______
18. / Other building consultant fees:
______(fee______%) / ______
19. / Permits and inspection fees / ______
20. / Other (must specify): ______/ ______
21. / TOTALBUILDING COST / ______
Equipment Cost
22. / Fixed equipment cost not in building contract / ______
23. / Movable equipment / ______
24. / Major technical equipment / ______
25. / TOTAL EQUIPMENT COST / ______
ATTACH A BRIEF NARRATIVE EXPLAINING ASSUMPTIONS USED FOR EACH LINE ITEM PROVIDED IN THIS SCHEDULE
AHCA Form 3150-0001 Schedule 1 Rev March-09Section 59C-1.008(1)(f), Florida Administrative Code
Page 1 of 2(38) Form available at:
SCHEDULE 1 /ALL APPLICANTS
Except Transfer of CON
/ ESTIMATED PROJECT COSTSPage 2 of 2
Project Development Cost
26. / Certificate of Need application fee / ______
27. / Feasibility studies, market surveys / ______
28. / Legal and accounting fees / ______
29. / Healthcare consultants fees / ______
30. / Other (must specify): ______/ ______
31. / TOTAL PROJECT DEVELOPMENT COSTS / ______
Financing Cost
32. / Financial consultant fees / ______
33. / Legal and underwriters’ fees / ______
34. / Loan of bond issue discount / ______
35. / Local application or origination fee / ______
36. / Title insurance (not included in land) / ______
37. / Loan closing costs / ______
38. / Bond and prospectus printing fees / ______
39. / Prospectus consulting fees / ______
40. / Construction period interest / ______
41. / Other (must specify): ______/ ______
42. / TOTAL FINANCING COSTS / ______
Start-Up Cost (must specify):
43. / ______/ ______
44. / ______/ ______
45. / ______/ ______
46. / TOTAL START-UP COST / ______
Other Intangible Assets and Deferred Costs (must specify): / ______
47. / ______/ ______
48. / ______/ ______
49. / TOTAL INTANGIBLE ASSETS AND DEFERRED COSTS / ______
50. / TOTAL PROJECT COST (lines 11+21+25+31+42+46+49) / ______
51. / PROJECT COST SUBJECT TO FEE (line 50 less line 26) / ______
ATTACH A BRIEF NARRATIVE EXPLAINING ASSUMPTIONS USED FOR EACH LINE ITEM PROVIDED IN THIS SCHEDULE
AHCA Form 3150-0001 Schedule 1 Rev March-09Section 59C-1.008(1)(f), Florida Administrative Code
Page 2 of 2(38) Form available at:
AHCA Form 1455A, Oct 92