state of connecticut

Appendix B- Forms and Completion Instructions

CO-1079 RECORD OF EQUIPMENT ON LOAN

Purpose: The purpose of this form is to provide the agencies with a standardized form for loaning equipment to employees, other agencies, municipalities, etc. If an agency currently has its own form it should be reviewed to compare the data on this standardized form.

Date
The date this agreement is entered into.

Report No.
Each agency should assign its own number to the form.

Individual's Name
Individual that is entered into this agreement.

Room
Enter Room Number where the equipment is normally located.

Address
Agency address where the equipment is normally located.

Building
Building number, if known.

Tag No.
Indicate the inventory tag number assigned to the property.

Serial No.
Indicate the manufacturer's serial number, if applicable.

Description/Condition
Enter a brief description of the item and its current condition.

Value
Enter the current cost or value of the item as indicated on the agency inventory records.

Usage of the Property
Indicate what the property will be used for.

Specific Unit
Indicate the specific unit of the agency that is borrowing the property.

Agency Name
Enter your agency's name.

Location of the Property
Give the complete address of where the property will be located.

Date of Return
Indicate the date the property will be returned to the agency.

Approved Director or Department Head Signature
Signature of the director or the department head.

Printed Name
Please print the name of the person that is approved to sign the release of the equipment.

Recipient Signature
Signature of the individual that is borrowing the property.

Printed Name
Please PRINT the name of the individual that is borrowing the property.

Date
Indicate the date that the property is actually returned to its location.

Building No. and Room No.
Enter the building number and the room number that the equipment was returned.

Please Note Any Exceptions
Please indicate any exceptions to the equipment upon its return for future reference.

Director or Department Head Signature
Signature of the director or department head of the unit that maintains the property.

Follow this hyperlink for an example of this form.

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