Purchasing PO10
SURPLUS MATERIAL DISPOSAL FORM
Department and Program/Project: ___________________________________
Date (YYYY-MM-DD):_________________________ Completed By: _____________________________________
PLEASE FILL IN THE FOLLOWING INFORMATION, WITH AS MUCH DETAIL AS POSSIBLE
Type of material/machine/equipment: ____________________________________________ Qty: _____
Manufacturers Name: _________________________________________________________
Model #: ______________ Serial #: ____________________________ U of W TAG#: __________________
General Description and use of Equipment: If multiple items are being disposed, please attach a detailed list
(Motor Data, Voltage, Cycle, Phase, RPM; accessories, Spare Parts, etc.)
Was Equipment under warranty of a Service Contract? Yes No If yes, with whom?
General Assessment of Condition: Poor Fair Good Excellent
Any broken or missing parts? _______ Rough estimate of repair cost if worth repairing: ______________________
Reason for declaration as surplus: _______________________________________________________________________
Present location of material - Bldg: ____________________________________________ Room #: _________
How soon must the material be removed? ________________________________ Est. total weight: ________
Estimated market value: ________________________
THE FOLLOWING INFORMATION SHOULD BE INCLUDED, IF AVAILABLE
Company originally purchased from:
Date of purchase: ___________________________ P.O. # issued: __________________
Value at time of purchase: ____________________ Current depreciated value: _____________________
Lowest bid acceptable for sale: _________________ Account number to be credited: _________________
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Your typed name below indicates your approval of the form and confirms that all information is accurate.
Disposal authorized by: (Department Head or Grantee) ______________________________________
Date: __________________
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TO BE FILLED IN BY PURCHASING SERVICES
Recommendation: Check one and add any additional information necessary
Inter University Transfer Outright Sale Scrap Other
_____________________________
Explain :
_________________________________________________________________________________________
_________________________________________________________________________________________
Disposal File #: ________________
Signature: __________________________________ Total price: ____________________
Cost relating to disposal: ______________________ Sales taxes paid: ________________
Amount recovered from transaction: _________________ Account credited: _______________________
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