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Relief from Property Accountability

Finance & Accounting - Controller's Modular

Office of the Controller
Phone: (239) 590 - 1228
Dept. Name: ________________________________________
Missing (Include UPD Report)
Provide the reasons or circumstances for this request (Choose One):
If donation, Recipient 501(c)(3)non-profit organization: ____________________________ Tax Exempt #________________
Street Address: ___________________________ City: _____________________ State: _______ Zip Code: _____________
Property Description of Property Age Acquisition EH&S (1)
Serial No. Condition Book Value
Tag # (including make & model) (Yrs.) Cost Approval

(1) All dispositions of medical and laboratory equipment must be pre-approved by EH&S and a Decontamination and Disposal form must be attached to this Relief from
Property Accountability Form.
I certify that the above statements are true and complete to the best of my knowledge and request that release of
accountability be given for the property.

Property Manager (Print) Signature Date

Accountable Officer (Print) Signature Date

(Asst. Dean/Director or above)

If stolen/missing: What will be done to prevent future occurrences:

To be completed by Property Survey Board

The Property Survey Board has met on ____________ and recommends the following:
Release of Accountability: Approved
Denied, see remarks

Member Signature Member Signature

Member Signature Member Signature

To be completed by the person witnessing of the disposition of the equipment

I have witnessed the disposition of the above referenced equipment.
(For internal controls, the witness cannot be the Departmental Property Manager.)

Witness Name (Print) Signature Date

** Please return completed form to the Property Accounting Department after the witness has signed this form.
Items will not be taken off inventory until the witness signature has been obtained.

Form Dated: 10/9/2018

Form: 8.IX.A

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