Form Ad-112 - Report Of Unserviceable, Lost, Stolen, Damaged Or Destroyed Property printable pdf download

U.S. DEPARTMENT OF AGRICULTURE

PROPERTY REPORT NO.

DATE

REPORT OF UNSERVICEABLE, LOST, STOLEN

DAMAGED OR DESTROYED PROPERTY

SECTION I - ACCOUNTABLE PROPERTY OFFICER'S REPORT

1. STATUS OF PROPERTY (Check only one - report each type separately)

2. REPORTING ACTIVITY (Show agency, unit, and address)

Lost or stolen

Unserviceable

Cannibalized for parts

Obsolete

Destroyed

Damaged

Others

3. PROPERTY ITEMS (See attachment for additional entries)

ITEM DESCRIPTION AND OTHER DETAILS, INCLUDING

EXPLANATION/DISPOSAL INSTRUCTIONS

QUANTITY

SERIAL NUMBERS AND ACQUISITION DATE

ACQUISITION COST

(If lost, stolen, or destroyed, give detail.

(Or property no.)

(Give present condition and estimated cost of repair)

Was this reported to proper authorities?)

(A)

(B)

(C)

(D)

4. NAME IN PRINT AND SIGNATURE OF CUSTODIAN DATE

5. NAME IN PRINT AND SIGNATURE OF

DATE

ACCOUNTABLE PROPERTY OFFICER

SECTION II - PROPERTY MANAGEMENT OFFICER'S REVIEW AND RECOMMENDATION

DETERMINATION FOR LOST, STOLEN, DAMAGED, OR DESTROYED PROPERTY

1. After due consideration of all known facts and circumstances in this case, it is determined that:

a. The loss, theft, damage, or destruction did not result from employee negligence and any involved employees are hereby relieved of liability.

b. There appears to be gross negligence involved; therefore, the case is returned to agency officials for appropriate action under the Debt

Collection Act.

c. There appears to be negligence involved; therefore, the case is returned to agency personnel officials for consideration of disciplinary action.

2. NAME IN PRINT AND SIGNATURE OF PROPERTY MANAGEMENT OFFICER

3. DATE

SECTION III - AUTHORIZATION FOR CANNIBALIZATION, ABANDONMENT, OR DESTRUCTION OF UNSERVICEABLE PROPERTY

1. Unserviceable property listed above is hereby authorized for cannibalization, abandonment, or destruction in accordance with FPMR 101-45.9 based on any of the following

determinations as further explained in section I-3 (D):

a. Property has no commercial value.

e. Property is uneconomical to repair/not needed by another user and

may be cannibalized for parts. (Cannibalization is a form of use

b. Health, safety, or security considerations require immediate

and property management regulations shall apply. Remainder of

abandonment or destruction.

property must be disposed of through usual procedures.)

c. Costs of care and handling exceed expected small lot sales

proceeds.

d. Regulation or directive requires abandonment or destruction.

2. SIGNATURE OF PROPERTY MANAGEMENT OFFICER

3. DATE

SECTION IV - CERTIFICATION FOR COMPLETION OF CANNIBALIZATION, ABANDONMENT, OR DESTRUCTION:

I certify that cannibalization, abandonment, or destruction action for the items authorized under Section III was completed on this date in accordance with I-3 (D).

1. SIGNATURE OF ACCOUNTABLE PROPERTY OFFICER

2. DATE

3. SIGNATURE OF WITNESS

4. DATE

SECTION V - CERTIFICATIONS OF PROPERTY AND FISCAL OFFICERS

1. SIGNATURE OF PROPERTY MANAGEMENT OFFICER (The necessary entries have been made to adjust property records.)

2. DATE

3. SIGNATURE OF FISCAL OFFICER (The necessary action has been taken to adjust the accounting records and, where required by a

4. DATE

determination made under Section II above, to effect collection from involved employee(s).)

AD-112 (Rev. 3/94)