Asset Retirement Initial Evaluation Request Form Please fully complete the form below, and we’ll get back to you shortly. Your InformationDate Date Format: MM slash DD slash YYYY Name* Phone*Email* Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Property InformationName of Property*Name of Entity*Physical Property Address*City*State*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZip Code*Description of Property at Time of Purchase (e.g.: industrial, office, retail, apartment)*Present Building Usage*Square Feet*Number of Floors*Number of Buildings*Purchase Date or Placed-In-Service Date (mm/dd/yyyy)Total Purchase Price or Project Cost (including land cost, if any)Amount of Purchase Price or Project Cost Allocated to Land Subsequent Building Improvment Costs1.Following info is year 1 improvements.YearAmountDescription2.Following info is year 2 improvements.YearAmountDescription3.Following info is year 3 improvements.YearAmountDescription4.Following info is year 4 improvements.YearAmountDescription5.Following info is year 5 improvements.YearAmountDescription DocumentsThe following documents are required: • Federal Tax Depreciation Schedule (If the property has been placed in service and a Federal Tax Return has been filed, the Federal Depreciation Schedule is required to complete the initial evaluation.) • Closing Statement -- If Available • Recent Appraisal (Cost Information) -- If Available Use the inputs below to upload the necessary files. FileFileFile Other Available DocumentsAre Any of the Following Documents Available? (Please check all that apply) AIA Payment Applications Project Budget Summary Change Orders Building Blueprints Building Blueprints Photos of New Assets Photos of Removed Assets Photos of Removed Assets Additional NotesEnter Any Additional NotesM&E RepresentativeName of Your M&E Representative