Free 01138.FH11 - Indiana


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Date: July 22, 2008
File Format: PDF
State: Indiana
Category: Government
Author: sbundy
Word Count: 904 Words, 5,676 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.state.in.us/icpr/webfile/formsdiv/01138.pdf

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CRESTA (Confirmation of Received Equipment / Services and State Tag Application)
State Form 1138 (R6 / 12-03) / PROC 2600

Reset Form

Order / PO number: IR number: F1 number:

TO: FROM: TELEPHONE: DATE: , FSSA Procurement

Return To: MS 36 / FSSA Procurement 402 West Washington Street Indianapolis, IN 46204 Rm. E414 ATTN:

TO: FROM: TELEPHONE: , FSSA Procurement

DATE: (Please Print Clearly) RE: Confirmation of Received Equipment / Services RE: State Tag Application See instructions on back side of form When you receive the shipment for this order, complete the following information, sign / date the form and return the original and any receiving slips to the address above. These items will be added to your inventory. Include a user name and location for each asset. Retain a copy for your records. Description / Brand Name of Item / Model #: User Name: Serial Number: Location / Room Number: Unit Cost: Remarks: Quantity Received: Monitor Serial Number: Tag Number:

Description / Brand Name of Item / Model #: User Name:

Serial Number: Location / Room Number:

Unit Cost: Remarks:

Quantity Received:

Monitor Serial Number:

Tag Number:

Description / Brand Name of Item / Model #: User Name:

Serial Number: Location / Room Number:

Unit Cost: Remarks:

Quantity Received:

Monitor Serial Number:

Tag Number:

Description / Brand Name of Item / Model #: User Name:

Serial Number: Location / Room Number:

Unit Cost: Remarks:

Quantity Received:

Monitor Serial Number:

Tag Number:

Description / Brand Name of Item / Model #: User Name:

Serial Number: Location / Room Number:

Unit Cost: Remarks:

Quantity Received:

Monitor Serial Number:

Tag Number:

I certify that the above items have been received, inspected, and accepted by this office.
Office / Section / County Equipment / Goods / Services received (sign / date) Telephone number

FOR PROCUREMENT USE ONLY
Date entry mode: Entered by:

Mailed Tag(s):

Proc. Tagged:

DTS Tagged:

Name:

INSTRUCTIONS FOR CRESTA
No payments will be made to the vendor until the completed receiving report is returned. All vendor calls regarding non-payment will be referred to your office if a CRESTA form has not been returned. As stated in Indiana code 5-17-5-1, unless there is contract language specifying the terms and conditions of payment, vendors are to be paid within thirty-five (35) days of vendors dated invoice. If payment occurs after day thirty-five (35), a penalty will be assessed. The rate of penalty will be one percent (1%) per month, compounded monthly, of the gross payment due to the vendor. Therefore, it is imperative that we do everything we can to submit a completed CRESTA form timely in order for payment to be made within the 35 day time period.

CRESTA RECEIVING REPORT (PLEASE PRINT CLEARLY)
1. Enter the description / Brand Name of item / Model Number (i.e.. IBM CPU 300PL mdl.#656590U) When receiving computers, please enter the monitor description / Brand Name / Model Number in the Remarks field (as shown below). 2. Enter the Serial Number. If the serial number is unclear, please give any possible serial numbers in the Remarks field. All equipment should list the serial number after S/N. 3. Enter the unit cost. 4. Enter the quantity received. While inputting first entry, please enter the total number of like items received in the first blank and then list each item individually on the following lines. (i.e.. See below for receiving 10 IBM CPU 300PLs)
Description / Brand Name of Item / Model #: IBM CPU 300PL 656590U User Name: John Doe Description / Brand Name of Item / Model #: IBM CPU 300PL 656590U User Name: Jane Doe Serial Number: 23XXXX Location / Room Number: Upstairs Rm. 5 Serial Number: 23XXX1 Location / Room Number: Basement Rm. 12 Unit Cost: $1,600 Remarks: 17 IBM Monitor mdl#651701N Unit Cost: $1,600 Remarks: 17 IBM Monitor mdl#651701N Quantity Received: 10 Monitor Serial Number: 24XXX1 Tag Number: Quantity Received: 10 Monitor Serial Number: 24XXXX Tag Number:

* Continue in this manner for each of the 10 PCs. 5. (If applicable) Enter the monitor serial number. Please list the monitor serial number with each PC received. Make sure that both the PC and monitor serial numbers are matched up with the proper user name. (see above example) 6. Tag number will be assigned after receiving report is sent back to Procurement. See below. 7. Enter the user name. If there is no assigned user name at the time this form is completed, please send an email to Wayne Hoskins when user name is assigned. The email should include the serial number, tag number, description, and user name of each piece of equipment listed. 8. Enter the Location / Room Number. This is a specific location. (i.e.. Server Room, Reception area) 9. Enter any problems, questions, or other remarks. 10. Repeat steps 1-9 for each piece of equipment received. ** When all entries are completed, please enter Office / County / Section, sign / date, and give your telephone number.

RETURN FORM TO PROCUREMENT FOR STATE TAG APPLICATION
The Return To: box contains the address and contact name to return form. After the paperwork is processed you will be receiving state tags for all equipment over $500. Your state tags will be attached to a copy of your CRESTA form. You will also notice that the tag number field has been filled in for each piece of equipment received (with a unit cost of $500 or more). MAKE SURE TO APPLY THE PROPER STATE TAG NUMBER TO THE PROPER SERIAL NUMBER LISTED ON THIS FORM. ** When tagging computers, apply the tag to the CPU (not the monitor). ** After tags are applied it is not necessary to return form to Procurement. Please retain for your records.