(1) Division/Office by 5nAkG24


									     DHS TRANSPORTATION MANUAL - EXHIBIT 21                                                                                    132

                                         Georgia Department of Human Services
                                                     VEHICLE LOAD SHEET

(1) Division/Office                               (2) Organization Unit/Contractor Name or Agency               (3) Director of Agency

                      County                      Street Address                     /P.O. Box                  Prepared by              /Date

                                                  City                               /Zip Code                  Area Code          Phone #       /Gist #

               VEHICLE #                      VIN#

A.        #                             B.

                      TAG #                                                                  VENDOR NAME

C.     G V                                   D.

                  ACQUISITION COST                                 ACUISITION DATE                    VEHICLE WEIGHT               STATUS: N/U

                                                     F.                                        G.                           H.

                           RESPONSIBLE ORGANIZATION CODE                                              MONTHS OWNED

I.                                                                                            J.

              BEGINNING MILES                             STATE INSURANCE:         Y/N/O

K.                                                   L.       IF OTHER, EXPLAIN

              MANUFACTURE NAME                                      TYPE VEHICLE                           MODEL YEAR

M.                                                   N.                                               O.

                      MODEL NAME                                       TYPE FUEL                             ENGINE SIZE AND TYPE

P.                                                   Q.                                               R.     CYL

               TRANSMISSION TYPE                                     VEHICLE USE

S.                                                   T.

              OPERATING CONDITION                              SPECIAL EQUIPMENT

U.                                                   V.


W.                                                   X.   ASSIGNED TO:
                                                                                           FUND SOURCE                         COUNTY

                       A. 1.   Date Vehicle Received

                       A. 2.   Date Vehicle Put Into Service

                       A. 3.   FPO # or Check #

     Form 4964 (5-87)

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