Free 13812.FH11 - Indiana

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NOTIFICATION OF SURPLUS STATE - OWNED PROPERTY
State Form 13812 (R4 / 2-05)

Date (month, day, year) Original Acquisition Cost Per Unit Was: Over $2500. Less Than $2500.

DEPARTMENT OF ADMINISTRATION Operations Div. / Surplus Property 601 W McCarty Street, Suite 100 Indianapolis, IN 46225

INSTRUCTIONS: 1. Place usable and non-usable items on separate forms. Place items requiring different dispositions on separate forms (all Sell on one form, all Transfer on a different form, etc.) 2. The agency completing this form is prohibited from disposing of surplus property without authorization from the Department of Administration 3. After authorization is given by Surplus Property Section, disposition agent must make changes to inventory. Name of Notifying State Agency Address of State Agency (number and street, city, ZIP code) Division Name of Disposition Agent Account Number for Deposit of Proceeds Telephone Number

The following items of state owned property have been determined to be surplus to agency needs: Quantity/Unit Description and Condition of Item(s) (List Make, Model, Year, I.D. or Serial No. For Motor Vehicles, See Note* Below.) If requesting to SELL item, indicate name of contact, phone number and minimum bid required Dispostion Requested Sell Trade Transfer Dispose Sell Trade Transfer Dispose Sell Trade Transfer Dispose Sell Trade Transfer Dispose Sell Trade Transfer Dispose Sell Trade Transfer Dispose Sell Trade Transfer Dispose Sell Trade Transfer Dispose
Original Acquisition Cost Original Purchase Fund

$

Usable

Non-Usable

$

Usable

Non-Usable

$

Usable

Non-Usable

$

Usable

Non-Usable

$

Usable

Non-Usable

$

Usable

Non-Usable

$

Usable

Non-Usable

$

Non-Usable Usable If applicable, all data has been removed from the computer storage device(s) (hard drives, PDAs, etc.) per the State of Indiana Enterprise Information Technology Security Policy Guideline.

Yes

No

N/A

Initials

* For Motor Vehicles, include Vehicle Identification Number (VIN), Commission Number, Mileage, and condition (POOR, AVERAGE OR GOOD)
I hereby affirm that the above listed state surplus property is as described and has not been disposed of by this agency without proper authorization from the Department of Administration. All information listed on this form is true and accurate. Signature of Disposition Agent Date Signed From To

DO NOT WRITE HERE - STATE SURPLUS USE ONLY APPROVED (Make necessary changes to inventory record)

DISTRIBUTION OF COPIES
Original: Department of Administration (Surplus Property/Operations Division) Copies: Department of Administration (Procurement Division) Disposition Agent File Receiving Agency (for transfers only) State Surplus will distribute copies after approval Signature of Approval Date signed