DEPARTMENT: ___________________________
THIS NOTIFICATION IS FOR: ADDITION UPDATE TRANSFER DISPOSAL
ACQUISITION IS BY: PURCHASE DONATION LEASE TRANSFER
(ATTACH COPY)
DATE OF TRANSACTION: ________________________________________
ACCOUNT NO. _______________ P. O. NO. __________________
ESTIMATED: LIFE EXPECTANCY _________ MILEAGE OR HOURS ________
CIP NUMBER: __________________ LOCATION: ___________________
SERIAL OR VIN NUMBER: ________________________________________
TOTAL/PARTIAL VALUE OF ASSET: _______________________________________
(PLEASE ATTACH OR FORWARD COPY OF CHECK(S) TO DOCUMENT COST.
IF DONATED FAIR MARKET VALUE, HOW DETERMINED, AND DATE BOARD APPROVED.)
DESCRIPTION: ___________________________________________________________________________
_________________________________________________________________________________________
(BUILDING DESCRIPTION MUST INCLUDE SQUARE FOOTAGE, BUILDING MATERIAL, ROOF TYPE, AND IF EQUIPPED WITH SPRINKLER SYSTEM OR BOILER.)
BRAND OR MAKE: _______________ MODEL NO.: _________________
YEAR: _______________________ LICENSE NO.: ________________
ATTACH COPY OF REGISTRATION
GROSS VEHICLE WEIGHT: ___________ TYPE OF FUEL: __________________
TRUCKS ONLY
IF DISPOSED-METHOD: SOLD $________ TRADED JUNKED SCRAPPED
STOLEN/WRECKED END-OF-LEASE TRANSFERRED TO: _____________
(ATTACH POLICE REPORT)
DATE BOARD APPROVED: ___________ DATE COUNCIL APPROVED: _______
(ATTACH COPY OF MINUTES) (REAL PROPERTY VALUE> $9,999)
DATE MAYOR APPROVED: ___________ SIGNATURE: _____________________________________
(REAL PROPERTY ONLY)
PERSON RESPONSIBLE: ___________________ ______________________________
SIGNATURE PRINTED NAME
RESPONSIBLE DEPARTMENT HEAD'S SIGNATURE: ________________________
IF TRANSFERRED
RECEIVING PERSON'S SIGNATURE: ___________________________________
PRINTED NAME: _________________________________
CLERK-TREASURER'S USE ONLY
RECEIVED: ______________________ ENTERED FIXED ASSET: ___________
INSURED: _______________________ CLERK-TREASURER'S INITIAL: _______