DI 103A

Transcript

1 DI-103A (Rev. 6/88) UNITED STATES of Page DEPARTMENT OF THE INTERIOR Certificate No. CERTIFICATE OF UNSERVICEABLE PROPERTY May only be used when property is unserviceable through fair wear and tear; there are no apparent Date property irregularities; no need to determine employee financial liability; no possible claims against the Government; firearms and weapons, ammunition, hazardous materials, controlled substances, explosives, or museum property are not included. Accountable Office and Location ) A. Originating Office and Telephone No. (include area code Identified Item(s) are: Unserviceable (specify) Other Obsolete STATEMENT OF CIRCUMSTANCES INVOLVING THE IDENTIFIED PROPERTY MUST BE ATTACHED CONDITION ORIGINAL QUANTITY ITEM ESTIMATED ITEM DESCRIPTION ACQUISITION OR CODE VALUE NO. See Reverse) ( COST (OAC) PROPERTY ID NO. Abandon Salvage Sale / Trade-in Repair / Reutilization (specify): Scrap / Destruction Other Recommended disposition (check one) : B. To the best of my knowledge the attached statement of circumstances is correct and recommendations are in the best interest of the Government. Date: Signature of Custodial Officer: Date: Signature of Cognizant Employee: Property Staff Recommendations: Date: Signature of Accountable Officer: Date: Signature: Signature: Date: Reviewing Authority: Approved Disapproved C. Comments Attached listed above has been destroyed. D. Certificate of destruction: I certify that the Item(s) No.(s) Signature: Title: Official Responsible for Destruction: Date: Date: Witness Name: Title: Signature: Date Completed: Financial Official (If Required): Date Completed: Adjustment to property records (Property Official E. Signature):

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