Fixed Asset Transfer Request Form

Receiving Custodian Name

Transfer Prepared By Date Prepared

Receiving Custodian No.

Department Code

Complete Address, (Area Code) Phone Number A5 - Interdepartmental Transfer

Asset Tag Number

Qty

AC A5 A5 A5 A5 A5 A5 A5 A5 A5 A5 A5 A5 A5 A5 A5 A5 A5 A5 A5 A5 A5 A5 A5 A5 A5

Description, Mfg, Model, Serial No., Color

Cost

Bldg

Room

Total Value of Additions Comment:

$0.00

Receiving Department Certification

"I assume inventory accountability for the above described equipment."

Signed: Department Head Date

Releasing Department Certification

"I relinquish inventory accountability for the above described equipment."

Signed: Department Head Date

Releasing Custodian Number

orm
Date

Owner Code

Date

Date