DATE:	NUMBERED PROPERTY
TO:	NON-NUMBERED PROPERTY
UNIT BUDGET MANAGER NAME	ADMINISTRATIVE UNIT
I certify that the following property, for which I was responsible, was damaged, lost, or stolen as indicated below. I understand that depending on the circumstances and the pending recommendation of the unit administrator and property officer that a penalty may be assessed.
SIGNED:	ADDRESS:
NAME (PRINT):
ITEM DESCRIPTION	QUANTITY	PROPERTY NUMBERS	DESCRIBE CIRCUMSTANCES UNDER WHICH PROPERTY WAS DAMAGED, LOST, OR STOLEN
Budget Manager must review all Property claims for his/her unit:	General Services Manager must review all Numbered Property claims:
ACTION RECOMMENDED BY BUDGET MANAGER	ACTION RECOMMENDED BY GENERAL SERVICES MANAGER
SIGNATURE	DATE	SIGNATURE	DATE
For Non-Numbered Property, forward copy to Fiscal if action requires billing employee.	For Numbered Property, forward copy to Fiscal if action requires billing employee.
INVENTORY PST APPROVAL:	DATE:
In cases of theft, attach copy of police report of investigation.