Section: 440-3 Exhibit B
Effective: 4/1/98
Supersedes:
Issuing Office: Real Estate Development (RED)

DATE:_______________

Forward completed form to Real Estate Development (0982). Questions may be directed to the Real Estate Development Office at x47480 or x21145.
REQUESTING DEPARTMENT INFORMATION

Requesting Department:_____________________________________________________________
Dept. Contact: ___________________________ Ext:_______________ Mail Code: __________
Fax Number:_____________________________E-mail Address: _____________________

NEW LEASE INFORMATION

Term:___________ to ___________ # of Individuals: _____ Parking Spaces Needed:___________
Options to Extend: Yes/No:____ Length of Term for Each:_________________________
Approx. Sq. Ft.: _______________________Approx. Rent: ______________________
Proposed Usage (be specific - include typical activities to be performed): ______________________

SITE INFORMATION
Please provide site information listed below. Real Estate Development will work with the department contact regarding lease negotiations. Please do not negotiate any lease terms:

IF REQUEST IS FOR A SPECIFIC SPACE:

Street Address of Property: ___________________________________________________
City, State, ZIP: _____________________________________________________________
Name of Landlord: __________________________________________________________
Landlord Contact: ___________________________________________________________
Landlord Contact Address: ____________________________________________________
Landlord Contact Telephone: __________________________________________________
Previous Use of Space: ________________________________________________________
Tenant Improvements Needed: _________________________________________________
(describe) ___________________________________________________________________

IF REQUEST IS FOR A GENERAL AREA:

Area of San Diego: ______________________________________________________________
(e.g., Kearny Mesa, Hillcrest, La Jolla)

IF THIS NEW LEASE INVOLVES A RELOCATION FROM YOUR EXISTING FACILITY COMPLETE THE FOLLOWING:

Current Address: ___________________________________Approximate Relocation Costs:
_________________________________________________Moving Cost $ _______
Landlord's Name/Address/Telephone:____________________Telephones $________
_________________________________________________Computers $________
_________________________________________________
Expiration Date of Current Lease:________________________Other:___________ $ ____________
Current Monthly Rent: $________________________

FUNDING INFORMATION FOR NEW LEASE AND RELOCATION COSTS (if applicable)

Funding Sources:	Relocation
New Lease Costs 
A)	State Support Letter	Percent of	Letter	Percent of
B)	User Fees Source	Source	Source	Source
C)	Federal Funds	D)	Medical School Clinic Fees _______ ______% ______ ______%
E)	Teaching Hospital/Medical Center _______ ______%	______ ______%
F)	Opportunity/Off-The-Top Funds	_______ ______%	_______ ______%
G)	Other: Specify Fund/Org Number:	Index Number *:	Indirect Cost Rate:	o On-Campus	o Off-Campus
*Any EH&S inspections/reviews required will be charged to this Index Number.
APPROVALS:
Department Chair	Date
FOR REAL ESTATE DEVELOPMENT OFFICE USE S.O.M. Dean's Office	FD&C (Seismic/ADA)	M.C. Director's Office	FD&C Engineering	EH&S(Health, Safety & Fire)	Physical Planning (EIC)	Dean, School of Medicine/Director Medical Hospitals & Clinics	Date

1. Date: The date the form is completed.

2. Requesting Department: The department that will be occupying the space.

3. Department Contact: To whom in the department should questions be directed? This should be the person who will be involved in the day-to-day administration of the Lease.

4. Contact Extension: Telephone number at which the department contact may be reached.

5. Mail Code: Mail Code of Department Contact.

6. Fax Number: Fax Number of Department Contact.

7. E-mail Address: E-mail Address of Department Contact.

8. New Lease Information: Complete the information requested for the new space to be leased.

9. Term of Lease: From what date to what date would the department like to occupy the space?

10. Number of Individuals: How many employees will be occupying the requested space?

11. Parking Spaces Needed: Ideal number of parking spaces to accommodate employees and visitors.

12. Options to Extend: If the department would like the option to extend the lease beyond the time specified in #9, how many options at what length are preferred? (i.e. two one-year options, one three-year option).

13. Approx. Sq. Ft.: The ideal space would contain how many square feet?

14. Approx. Rent: What rental amount is the department prepared to pay?

15. Proposed Usage: For what purpose (office, classroom, storage, etc.) will the space be used? In conjunction with what grant/program/activity?

16. Site Information - SHADED AREAS: Must be completed if a proposed space has been located prior to completion of this form, or if only a general area is known.

17. Street Address of Property: Address of proposed space. Include any suite or apartment numbers.

18. City, State, ZIP: City, State, and ZIP Code of proposed space.

19. Name of Landlord: Legal name into which the Lessor will enter the contract.

20. Landlord Contact: The person to work with on behalf of the Landlord.

21. Landlord Contact Address: The address of the person to work with on behalf of the Landlord.

22. Landlord Contact Telephone: Telephone number at which to reach Landlord Contact.

23. Previous Use of Space: For what type of operations was the space previously used.

24. Tenant Improvements Needed: Will modifications to the space be required for Tenant to occupy the space.

25. Request for a General Area: Indicate the area(s) of San Diego the proposed space where department needs to be located.

26. Relocation Information: Information regarding the current space occupied by the department. Information includes estimated department relocation costs.

27. Current Address: Current address of department.

28. Landlord's Name/Address/Telephone: Miscellaneous information for current Landlord.

29. Expiration Date of Current Lease: When does the Lease Agreement for the department's current space expire.

30. Current Monthly Rent: Amount of monthly rent being paid for the department's current space.

31. Approximate Relocation Costs: Obtain from the appropriate departments the approximate costs required to relocate the department to the new space being requested. This will assist the department in determining the total cost obligation involved in the new off-campus space request.

32. Funding Information: Where does the money come from to pay the rent, operating expenses, relocation costs, if applicable.

33. Funding Sources: Sources identified for rent, operating expenses, and relocation costs. Each source has a corresponding letter which is to be used in identifying the fund source under the New Lease and Relocation Costs columns.

34. New Lease: Identify the fund source(s) and percentages that will pay the rent and operating expenses.

35. Relocation Costs: Identify the fund source(s) and percentage that will pay the relocation costs, if applicable.

36. Fund/Org. Number: Identify the fund and organization numbers.

37. Index Number: An Index Number to charge copying, mailing, EH&S and FD&C Inspections.

38. Indirect Cost Rate: If an Indirect Cost Rate will be used, indicate if it is ON-CAMPUS or OFF-CAMPUS.

39. Approvals: Obtain the necessary approvals prior to submitting to Real Estate Development.