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Complete one form for each building that is leased for education use. Submitted forms can be typed or handwritten.

CHARTER SCHOOL NAME: Enter the official name of the charter school as approved in the charter.

ADMINISTRATIVE UNIT NUMBER: Enter the nine-digit number assigned by the Department of Education to the charter school.

COUNTY: Enter the name of the county in which the administrative office of the charter school is located.

CONTACT PERSON: Enter the name of the person who is knowledgeable about the information contained in the application and can answer questions on the lease and the lease rental payments.

TITLE OF CONTACT PERSON: Enter the job title of the contact person.

TELEPHONE NUMBER AND EMAIL ADDRESS: Enter the telephone number and email address of the contact person.

ADDRESS OF LEASED BUILDING: Enter the street name, city, state, and zip code for the location of the leased building.

GRADES HOUSED IN LEASED BUILDING: Enter the grades housed in the leased building. For example, if the charter school includes a kindergarten program to 5th grade, enter “K-5.”

IS THIS A CYBER SCHOOL?: Enter either yes or no.

IS THE LEASED BUILDING A RELOCATABLE STRUCTURE/TRAILER/MODULARIZED STRUCTURE?: Lease rental costs for land, trailers, and modulars are not eligible for reimbursement under this program. If you check “Yes” to this question, those rental costs are not reimbursable unless the definition of “permanent” in Attachment B is met.

HAS THE LEASED BUILDING BEEN INSPECTED AND APPROVED FOR OCCUPANCY BY THE PA DEPARTMENT OF LABOR AND INDUSTRY OR THE LOCAL MUNICIPALITY?: If the building was inspected and approved for occupancy by the PA Department of Labor and Industry and/or by officials from the local municipality, check “Yes” and enter the approved occupancy date. If the building was not inspected and approved for occupancy, check “No” and explain why the building was not inspected. Use additional sheets if necessary.

NAME OF LESSOR: Enter the name of the party listed in the lease agreement.

TERM OF LEASE: Enter lease start and end dates. For example, if the charter school signed a five year lease, enter the start date (September 1, 2010) and end date (August 31, 2015).

HOW ARE PAYMENTS MADE TO LESSOR?: Check the appropriate payment period.

REIMBURSABLE ANNUAL LEASE COSTS: Enter the amount of annual lease payments for fiscal year 2017-2018. Please note that the lessor will be required to certify the annual lease rental payment was made by the charter school on the PDE-419 Form.


  • Line A (GROSS ANNUAL LEASE COSTS): List the gross amount of the lease rental costs for the applicant building. The total reported here must agree with the sum total of the payments reported monthly, quarterly, semi-annually or annually.
  • Line B (LESS NON-REIMBURSABLE COSTS): If the Gross Annual Lease Costs include fees/charges for operating and maintenance, such as utilities, janitorial or custodial services, list these costs here.
  • Line C (NET ANNUAL LEASE COSTS): Subtract Line B from Line A to determine the net annual lease costs. The Commonwealth will only reimburse on these costs, less income from other sources, including, but not limited to, building insurance income and the income from the sublease of space to another entity.

BOARD CERTIFICATION: Enter the date on which the charter school board acted to approve the application, the vote of the board members, and the other information requested in this section. An original signature by the board secretary is required. Signature stamps, photocopies, scanned and faxed signatures will not be accepted. Use of blue ink is suggested.

RETENTION OF DOCUMENTS: Appropriate documentation must be maintained for review by the Auditor General’s Office to support the charter school’s submission of the PDE-418 form and Chief Executive Officer Verification Statement.