7/29/2019 Custody Receipt

1/1

NOAA FORM 37-40 (1/99)

PE R SO NA L C U STO D Y PR O P E RTY R E C O R D/H A ND R EC E IPT

PROPERTY ISSUED TO:

NAM E: (LAST) (FIRST) (M.I.)

DIVISION/BRANCH LOCATION:ROOM /BUILDING

HOM E PHONE NO.

Statement of Respon sibility:

I have received the item(s) listed below on the date indicated. I accept personal responsibility for the property and w ill surrender it upon demand,transfer, or separation from the G overnment. I further understand th at failure on m y part to exercise responsibility for the care and p rotection of theitem(s) listed below could result in pecuniary liability established in accordance w ith DOC P ersonal Property M anagement Policy M anual, Part 4.9.

BA R CODE NUM BER DESCRIPTION(INCLUDING M AKE, MODEL, SERIAL NUIM BER AND ACCESSORIES)

COST

N A M E O F P ER SO N R EC EIV IN G P RO P ER TY T ELEP H ON E N O. IT EM S A RE T O B E R ET UR NED T O:ISSUING OFFICE LOCATION

SIGNATURE: DATE

NAM E OF ISSUING PROPERTY CUSTODIAN: RETURNED: DATE

SIGNA TURE: RECEIVED - S IGNATURE OF PROPERTY CUSTODIAN:

Reset