ࡱ> RTQ bjbj Nxx*$POk^(GWWW222V22WWRWWWE.0^   2Z@4222d222^ 222222222 : PRIVATE SCHOOLS FOR STUDENTS WITH DISABILITIES PRESCRIBED COST OF OWNERSHIP FORMAT FOR A RELATED PARTY TRANSACTION REAL AND PERSONAL PROPERTY FOR THE 2013-2014 SCHOOL YEAR (To be completed and attached to all related party lease/rental agreements) 1. Lessor 2. Lessee 3. Type of Property Leased/Rented: ____ Real Estate ____ Equipment 4. Description of Property 5. Term of Lease from to 6. Type of Lease (please check one): ____ Open ____ Closed End 7. Annual Lease Payment(s): Year 1. _____________ 2. _____________ 3. _____________ 4. _____________ 5. _____________ 6. _____________ 7. _____________ 8. _____________ 9. _____________ 10. _____________ 8. Is this a sub-lease? If so, please attach a copy of the primary lease to this form. ____ Yes ____ No 9. Is the property leased by the private school for students with disabilities also leased/used by another organization or individual? ____ Yes ____ No If yes, see #12. 10. Does the lessor conduct other business on any portion(s) of the property leased by the private school? ____ Yes ____ No If yes, see #12. 11. If the lease involves personal property, does the lessor also lease equipment to other parties in addition to the private school for students with disabilities? ____ Yes ____ No If yes, see #12. 12. When determining the Anticipated Costs of Ownership Per Year allocated to the private school lease, the lessor must only include those costs specifically associated with the private school lease or an allocated portion based on square footage, usage or revenue, etc. The Costs of Ownership must include anticipated dollar amounts in column (3) all other leases, column (2) allocated to private school lease and the total of columns 2 and 3 in column (1) total.  FILENAME \p \* MERGEFORMAT Z:\Annual Information\2013-2014\2013-2014 Related Party Form final.doc Anticipated Costs of Ownership Per Year 2013-2014 Lessor Lessee Description (1) Total(2) Allocated to Private School Lease (3) All Other Leases 1. Depreciation ______________ ______________ ______________ 2. Mortgage Interest ______________ ______________ ______________ 3. Real Estate Taxes ______________ ______________ ______________ 4. Property Insurance ______________ ______________ ______________ 5. Maintenance ______________ ______________ ______________ 6. Repairs ______________ ______________ ______________ 7. Insurance ______________ ______________ ______________ 8. Other (Itemize) ______________ ______________ ______________ _____________________ ______________ ______________ ______________ _____________________ ______________ ______________ ______________ _____________________ ______________ ______________ ______________ Total Anticipated Costs ______________ ______________ ______________ Allowable Return @ 2.5% of Column 2 ______________  Total Lease Amount ______________  If one or more of questions 9 through 11 on pages 1 and 2 were answered yes, please explain the method used to allocate costs between the private school lease and all other leases. Use the back of this page, if needed. NEW JERSEY STATE DEPARTMENT OF EDUCATION DIVISION OF FINANCE affidavit I hereby certify that all information contained on pages 1 through 4 of this form and submitted to the Division of Finance, New Jersey State Department of Education by the undersigned is to the best of my knowledge accurate. I also certify that if applicable (see items 9-11), the costs associated to the private school lease were allocated equitably based on square footage, usage, revenue or another equitable allocation method as appropriate and the costs identified in column 2 are not the entire cost of the lessor. _______________________ ____________________________________ (Date) (Signature of Lessor) This affidavit must be executed before an individual authorized by law to administer oaths. State of _______________________________ County of ____________________________ on the ________ day of ____________________, 20____. ______________________________ personally appeared before me and is known to be the individual described in, and who executed the foregoing instrument, and they duly acknowledge to me, that they executed the same, and that the statements contained therein are true. ___________________________________ ____________________________________ (Signature of Public Notary) (Signature of Lessor) Seal ____________________________________ (Official Title)  FILENAME \p \* MERGEFORMAT Z:\Annual Information\2013-2014\2013-2014 Related Party Form final.doc     2 PAGE  - 3 - "'()./Utu         " # $ & ( ) * + ` } ! 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