HomeMy WebLinkAbout05.a.02.a Asset Disposal Form - Asset No. 13739 AGENDA ITEM 5-a.2.a
REQUEST FOR SURPLUS DECLARATION AND/OR
ASSET DISPOSAL AUTHORIZATION
11/04/26
Asset# Description Serial #
13739 Fujitsu Scanner 406361
Clay County Utility Authority
Equipment Update Form
Disposal/Surplus Section:
Surplus removal Dispose
Surplus placement (location)
(If Requesting Disposal, please indicate reason below)
Lost Cannibalized Stolen/Vandalized
Obsolete Returned to Vendor
Damaged Date Agenda Approved
* If Stolen/Vandalized, please provide a copy of the police report.
Asset # Item Description (Make/Model) Serial #
13 7 31 1 6I90-z Color btArlex H0636 I
Dept Name: Develor1.�en�- Serv,ces Requested by: A dv,ew M0-clu, 4
Dept Head Approval: ffii_act-16`°4- Date: \fl11•%\l'149
Final Disposal Details
Method of Disposal: Date:
Details/Comments:
Person Disposing: Date:
Witness: Date:
Transfer/Loan Section (between departmental offices ):
Transfer Loan
Asset # Item Description (Make/Model) Serial # Est Return Date
I acknowledge receipt of the above referenced equipment. I will return this equipment when it
is no longer required, in the same condition, or better than I received it.
Grantor (from) Grantee (to)
Dept Name: Dept Name:
Custodian: Custodian:
Today's Date: Today's Date: