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: s VENTIST <br /> For gi :E ay( <br /> } 1 } A) .I. Y S '1' 1.:1 Received Date: <br /> Contract Number: <br /> Contract Review Submission Form <br /> (For an explanation of the process, documentation requirements, and fair market value information, <br /> see the "Contract Review and FMV 2006" document located on the AHS Intranet) <br /> 1. AHS entity name: Florida Hospital Zephyrhifls, Inc. <br /> 2. Primary contact for this contract: <br /> Name: Donald Welch Title: CFO Phone: 813 - 783 -6100 <br /> 3. Contracting parties: Florida Hospital Zephyrhills, Inc. & MICHAEL L. and ANGELA M. <br /> CASELNOVA, <br /> 4. Does the non -AHS contracting party have any other contracts with this or any other AHS entity? <br /> If "Yes ", please provide a description of the other contracts_ <br /> other contracts Yes <br /> 5. Type of contract: Lease <br /> Explain if "Other": explanation <br /> 6. Planned execution date: 02/01/09 Effective date: 02/01/09 Term (months): 60 <br /> 7. Contract summary and services to be provided: Contract is to lease 3,200 square foot medical <br /> office building for $15 a square foot for office space. <br /> 8. How does this contract further the facilities exempt purpose and benefit the community? <br /> It allows us to have storage and additional office space instead of remodeling in the hospital. <br /> 9. What are the dollar amount, frequency, and other financial terms of the arrangement? <br /> The lease is $15 a SF or $48,000 year for five years. At the end of 5 years the contract can he <br /> renewed for $17 a SF for an additional 2 years. <br /> 10. How was the compensation amount determined? a review of rents and leases in the market is <br /> attached. <br /> 11. What is the source of the fair market value documentation: <br /> 12. Is compensation above the 50 and less than the 75 percentile? IA <br /> If "Yes ", please provide an explanation (special skills, experience, market demands): ri Yes <br /> explanation <br /> 13. Is compensation equal to or above the 75 percentile? <br /> If "Yes" please provide separate documentation supporting I I Yes ( ( <br /> the document titled "Contract Review and FMV 2006 " on the AHS Intranet). <br /> high compensation sE <br /> 14. "Disqualified Person" Determination: For initial determination of whether or not the contracting pa <br /> considered "disqualified ", please answer the following. If any items are checked "yes ", it may diicai <br /> an additional review will be needed by the Intermediate Sanctions committee. The "Primary Contact <br /> listed above may be contacted to assist in a final determination. <br /> Re,i ,rri 1nr1 Inc <br />