SCHEDULE 1 (Continued)

SCHEDULE 1 (Continued)

SCHEDULE 1-Trn /

TRANSFER OF A

CERTIFICATE OF NEED

/ PROJECT COSTS
Page 1 of 2
ESTIMATED
PROJECT
COSTS / For TRANSFERS that EXCEED ORIGINAL TOTAL PROJECT COST
ACTUAL COST / DIFFERENCE
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 3150-0003 (2) Schedule 1(TRN) Rev March-09 Section 59C-1.008(1)(f), Florida Administrative Code

Page 1 of 2 (8) Form available at:

SCHEDULE 1-Trn /

TRANSFER OF A

CERTIFICATE OF NEED

/ PROJECT COSTS
Page 2 of 2
ESTIMATED
PROJECT
COSTS / For TRANSFERS that EXCEED ORIGINAL TOTAL PROJECT COST
ACTUAL COST / DIFFERENCE
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 3150-0003(2) Schedule 1(TRN) Rev March-09 Section 59C-1.008(1)(f), Florida Administrative Code

Page 2 of 2 (8) Form available at:

AHCA Form 1455A, Oct 92