RECORD OF PROPERTY ON LOAN

CO-1079 REV 2/2016

STATE OF CONNECTICUT
OFFICE OF THE STATE COMPTROLLER

DATE

REPORT NO.

IS AUTHORIZED TO REMOVE FROM ROOM

NAME

AT

.

ADDRESS, CITY

THE FOLLOWING PROPERTY:

TAG NO.

SERIAL NO.

DESCRIPTION

CONDITION

COST OF ASSET

THE PROPERTY WILL BE USED FOR

PROJECT

WHICH IS RELATIVE TO WORK BEING DONE IN THE

SPECIFIC UNIT

AT THE

AGENCY NAME

THE PROPERTY WILL BE LOCATED AT

GIVE COMPLETE ADDRESS

UNTIL

AT WHICH TIME IT WILL BE RETURNED TO THE AGENCY.

DATE OF RETURN

THE ABOVE NAMED INDIVIDUAL WILL BE RESPONSIBLE FOR LOSS DUE TO THEFT OR OTHER CAUSE AND ANY DAMAGE AND WILL PROVIDE DUE CARE AND SECURITY FOR THE ABOVE DESCRIBED PROPERTY UNTIL THE PROPERTY IS RETURNED TO THE AGENCY.  IN THE EVENT OF A THEFT, A COPY OF A POLICE REPORT MUST ACCOMPANY THE NOTIFICATION TO INVENTORY CONTROL TO REMOVE AN ITEM FROM THE ASSET LISTING.  THE RECIPIENT WILL BEAR RESPONSIBILITY FOR THE RETURN OF PROPERTY IN THE SAME CONDITION AS AT THE TIME OF RELEASE.

APPROVED DIRECTOR OR DEPARTMENT HEAD SIGNATURE

PRINTED NAME

RECIPIENT SIGNATURE

PRINTED NAME

COMPLETE AND PROVIDE A COPY TO THE PROPERTY CONTROL MANAGER.  RETAIN A COPY AND COMPLETE THE LOWER PORTION UPON RETURN OF THE PROPERTY.

DATE

THE ABOVE PROPERTY HAS BEEN RETURNED TO 

IN THE SAME CONDITION AS, IT WAS ACCEPTED

BUILDING NO. AND ROOM

AT THE TIME OF THE LOAN, WHERE REASONABLE EXPECTED.

PLEASE NOTE ANY EXCEPTIONS:

DIRECTOR OR DEPARTMENT HEAD SIGNATURE

RECIPIENT SIGNATURE

PROVIDE COPY TO PROPERTY CONTROL MANAGER