Lost or Stolen Property Statement

Fill out this form and print two (2) copies. Submit 1 copy to ASSET MANAGEMENT. Retain 1 copy for your records.
I. Employee Information:
EMPLOYEE:	DEPT:	PHONE:	ISSUED:

The following information is required to support the preparation of a Property Survey Report (STD 152). A Lost Property Statement form is prepared with each Surplus Property Survey Request (Form 116) when the request is for the survey of equipment items that are reported as lost or stolen. The campus Property Survey Board will also use the information provided to assist them in carrying out their assigned responsibilities.

1.	Was the room locked?	Yes	No
2.	Was the equipment secured with a locking device?	Yes	No
3.	State the precautions that were, and , or will be taken to prevent re-ocurrence of such loss: (TEN LINES MAXIMUM)

II. Authorizations:
*Signature: ____________________________________*	*Date: ________*
PROPERTY CONTROL DESIGNEE
Print Name:
*Signature: ____________________________________*	*Date: ________*
DEPARTMENT HEAD/COLLEGE DEAN
Print Name:

Please provide copies for the Property Control Designee, Department Head, and/or College Dean.

ASSET MANAGEMENT USE ONLY:

a. Estimated actual value:

b. Crime Report Number: