Surplus Property Disposition

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					 WV-103 Inventory Form                                                                 STATE OF WEST VIRGINIA                                                                                   Page        of
 Rev. 06/01/03
                                                                        Purchasing Division            ----      Surplus Property Unit
      Date                                                         SURPLUS PROPERTY RETIREMENT FORM                                                                 Retirement Number
                                       (For use when retiring equipment with an acquisition cost of $1,000 or less and not on the WVFIMS Fixed Assets System)              [To Be Assigned by the Agency]

      Department Name                                          Org #:
                                                               Object Code:                                   Recommended Disposition Method                        Submit Completed Form to:
      Department Address                                                                                                     (CHECK ONLY ONE)

                                                                                                                Agency Will Deliver to Property (1)                      Purchasing Division
      Division Name and Address
                                                                                                                  Request Pickup by Surplus Property (2)            Administrative Services Section
      Specific Location of Equipment                                                                              Request Sale on Site (3)
                                                                                                                                                                         Surplus Property Unit
                                                                                                                  Sell for Scrap Value (4)
      Agency Inventory Coordinator                                                                                                                                         2700 Charles Ave
                                                                                                                  Send to Landfill (5)
      Telephone # ( )                              FAX # ( )                                                                                                              Dunbar, WV 25064
                                                                                                               [Use one disposition method per form]

                         INFORMATION ON THIS FORM MUST BE TYPED OR CLEARLY PRINTED WHEN SUBMITTED TO THE SURPLUS PROPERTY UNIT, PURCHASING DIVISION

  Inventory        No. of                                               Original Acq       Acquisition Date      PO Number                        PO Date                       Physical Condition, Age, and
                                          Description
    Tag #          Units                                                    Cost               Model                  Make                      Serial Number                    Estimate Cost of Repairs




              The items listed on this form are not part of my agency’s WVFIMS Fixed Asset Inventory                                                   Recommended Disposition Method
Agency Authorized Signature                                              Title
                                                                                                                                                                           Approved
I do hereby certify that I have this day witnessed disposal by the Surplus Property Unit
                                                                                                                                                                           Disapproved

Agency Signature                                     Title                                                     Date
                                                                                                                                                   If Disapproved, Preferred Disposition Method
This retirement document has been completed by the Surplus Property Unit                                                                                      is No.      (see above)

Signature                                                 Title                                                Date                                             Manager of Surplus Property Unit
Distribution:
    Agency send original and one (1) copy to the Surplus Property Unit.
    Agency retain copy for their files.                                                                                                                                       Date
 WV-103A Inventory Form-                                                   STATE OF WEST VIRGINIA                                       Page     of
 Continuation Sheet
  Rev. 06/01/03                                            Purchasing Division        ----      Surplus Property Unit                   Retirement Number
                                             SURPLUS PROPERTY RETIREMENT CONTINUATION SHEET
                       INFORMATION ON THIS FORM MUST BE TYPED OR CLEARLY PRINTED WHEN SUBMITTED TO THE SURPLUS PROPERTY UNIT, PURCHASING DIVISION

Inventory          No. of                                   Original Acq     Acquisition Date     PO Number               PO Date          Physical Condition, Age, and
                                      Description
    Tag #          Units                                        Cost             Model              Make                Serial Number       Estimate Cost of Repairs




                                        The items listed on this form are not part of my agency’s WVFIMS Fixed Asset Inventory

				
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posted:7/24/2012
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