ADEQUATE
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REPORT OF ADJUSTMENT TO STATE-OWNED
REAL AND PERSONAL PROPERTY

CO-853 Rev. 12/2019

DATE OF DISCOVERY

INSTRUCTIONS:

1.  USE THIS FORM TO MAKE ADJUSTMENTS TO STATE-OWNED REAL AND PERSONAL PROPERTY.  ADJUSTMENTS MAY INCLUDE BUT ARE NOT LIMITED TO: THEFT, VANDALISM, LACK OF SUPPORTING DOCUMENTATION, CRIMINAL OR MALICIOUS DAMAGE, MISSING ITEMS, SPOILED OR EXPIRED PRODUCTS, LOST OR MISPLACED FUNDS, OR ITEMS RECOVERED.  NOTIFY LOCAL POLICE, OR, IF APPLICABLE, LOCAL SECURITY DIVISION IF LOSS IS CAUSED DUE TO CRIMINAL ACTIVITY.

2.  PREPARE AND ELECTRONICALLY SUBMIT THE FORM TO OSC.CO-853@CT.GOV. SUBMIT A COPY ELECTRONICALLY TO AUDITORS OF PUBLIC ACCOUNTS AT DONNA.G.MOORE@CGA.CT.GOV AND STATE INSURANCE AND RISK MANAGEMENT BOARD AT 
EILEEN.MCNEIL@CT.GOV. RETAIN ONE COPY ELECTRONICALLY FOR YOUR FILE.

     QUESTIONS: ACCOUNTS PAYABLE DIVISION, 165 CAPITOL AVENUE, HARTFORD, CT 06106 (860)702-3440

AGENCY NAME AND ADDRESS

LOCATION OF PROPERTY PERTAINING TO ADJUSTMENT

BRIEF DESCRIPTION OF PROPERTY 

REASON FOR ADJUSTMENT

REPLACEMENT VALUE (Make the necessary adjustments to your property control records as required)

1)   DATE PURCHASED OR RECEIVED AND TAG # :

2)   VALUE REPORTED ON THE ANNUAL INVENTORY REPORT TO THE COMPTROLLER (CO-59) :

 $ 

3)   DEPRECIATED VALUE :

 $ 

4)   COST IF NOT REPORTED ON CO-59 :

 $ 

SECURITY (Indicate by placing a checkmark in the appropriate block)

WHAT STEPS HAVE BEEN TAKEN WITHIN YOUR AGENCY TO PREVENT A RECURRENCE?  EXPLAIN:

IF ITEM WAS NOT REPORTED IMMEDIATELY, INDICATE REASON FOR DELAY

NAME OF INDIVIDUAL TO BE CONTACTED RELATIVE TO ADJUSTMENT

AREA CODE TELEPHONE NUMBER

(

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DATE