STATE OF WEST VIRGINIA
Purchasing Division — Surplus Property Unit
SURPLUS PROPERTY RETIREMENT FORMSURPLUS PROPERTY RETIREMENT FORM
Department Name
Org #:
Object Code:
Department Address
Page _____ of ____
Recommended Disposition Method
(CHECK ONLY ONE )
Division Name and Address
Specific Location of Equipment
Agency Inventory Coordinator
FAX # ( )
Submit Completed Form to:
Purchasing Division
Administrative Services Section
Surplus Property Unit
2700 Charles Avenue
Dunbar, WV 25064
Recommended Disposition Method
[ ] Approved
[ ] Disapproved
If Disapproved, Preferred Disposition Method
is No. ____ (see above)
Manager of Surplus Property Unit
Agency Signature _______________________ Title _____________________________ Date _______________
I do hereby certify that I have this day witnessed disposal of equipment listed above in the manner approved
Agency Authorized Signature
Title
WV-103 Inventory Form
Rev. 06/01/03
oo Agency Will Deliver to Property (1)
oo Request Pickup by Surplus Property (2)
oo Request Sale on Site (3)
oo Sell for Scrap Value (4)
oo Send to Landfill (5)
[Use one disposition method per form]
Date
Acquisition Date
Physical Condition, Age, and
Estimate Cost of Repairs
The items listed on this form are not part of my agency's WVFIMS Fixed Asset Inventory
No. of
Units
INFORMATION ON THIS FORM MUST BE TYPED OR CLEARLY PRINTED WHEN SUBMITTED TO THE SURPLUS PROPERTY UNIT, PURCHASING DIVISION
Model Make
Serial Number
PO Number PO Date
Description
Original
Acquisition Cost
Distribution:
• Agency send original and one (1) copy to the Surplus Property Unit.
‚ Agency retain copy for their files.
(For use when retiring equipment with an acquisition cost of $1,000 or less and not on the WVFIMS Fixed Assets System)
Retirement Number _____________
[To Be Assigned by the Agency]
Telephone # ( )
Date
This retirement document has been completed by the Surplus Property Unit.
Signature ________________________________ Title ___________________________ Date ________________
Inventory
Tag #
