Da Form 4697 - Department Of The Army Report Of Survey
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1
2DEPARTMENT OF THE ARMY
1. DATE PREPARED
2. SURVEY NUMBER
REPORT OF SURVEY
For use of this form, see AR 735-5; the proponent agency is ODCSLOG
3. TYPE OF PROPERTY
4. ADDRESS OF ACCOUNTABLE OFFICER
5. ORIGINATOR (Accountable officer, or primary hand receipt holder)
6.
7.
8.
9.
10.
NATIONAL STOCK NUMBER
ITEM DESCRIPTION
QTY
UNIT PRICE
TOTAL COST
11. DATE AND CIRCUMSTANCES
12.
SIGNATURE AND DATE
13. Subscribed and sworn to (or affirmed)
AFFIDAVIT
before me at
I do solemnly swear (or affirm) that (to the best of
this
day of
my knowledge and belief) the articles of public
TYPED NAME, GRADE, AND SSN
NAME AND GRADE (type and sign)
property shown above and/or on attached sheets
were lost, destroyed, damaged, or worn out in the
manner stated, while in the public service.
14. DATE
15. NAME, GRADE, AND SIGNATURE OF ACCOUNTABLE OFFICER
16. DOCUMENT NUMBER
17. APPOINTING AUTHORITY
I have received the evidence pertaining to the lost, damaged, or destroyed property, and have determined that the following action is required.
a.
No further investigation is required. There is no positive evidence of negligence. I do not suspect willful misconduct, or
deliberate unauthorized use. I hereby forward this document to the approving authority for final action. (Proceed to block 37.)
b.
The circumstances surrounding the lost, damaged or destruction warrants further investigation. (Proceed to block 21.)
c.
Conduct an investigation according to AR 15-6. Attach this document, as an exhibit, to the investigation and forward
it to the approving authority.
18. DATE
19. TYPED NAME, GRADE, AND TITLE OF APPOINTING AUTHORITY
20. SIGNATURE
DA FORM 4697, SEP 81
DA FORM 4696(TEST), 1 JUL 78 and DA FORM 4697(TEST),
USAPPC V3.00
1 JUL 78 ARE OBSOLETE.
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