Employee Personal Property Declaration Form Ccf-122 - Clark County School District
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2CLARK COUNTY SCHOOL DISTRICT
9998-500122
CCF-122 2/98
EMPLOYEE PERSONAL PROPERTY DECLARATION FORM
TOTAL OF ALL LISTED ITEMS SHOULD NOT EXCEED $1,000.00
Employee Name:___________________________________________________________________
Work Location: ________________________________________
Room No.______________________
Private Property Carrier (Homeowners/Tenants Insurance)
_____________________________
______________________________________________ Policy No. ______________________________
Please attach copy of insurance policy declaration page
Date of
Purchase
Description
Work Usage
Purchase
Price
1.
2.
3.
4.
5.
6.
7.
8.
I affirm that the above is true and correct to the best of my knowledge.
_______________________________________________
_____________________________________
Employee Signature
Date
I have reviewed this form in accordance with applicable district regulations.
______________________________________________
_______________________________________
Site Administrator’s Signature
Date
White - Administrator
Yellow- Employee
Gac 122
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Parent category: Financial