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Purpose: This form is to report all losses or damage to real and personal property, other than motor vehicles, pertaining to theft, vandalism, criminal or malicious damage, lost or misplaced funds. This form is also used to report expired, spoiled or obsolete inventory.
Date of Loss - Enter the date the loss or damage occurred.
Date Comptroller Notified - Enter the date the Comptroller's Office was notified.
Agency (Name and Address) - Enter the agency's name and address.
Location of Property Pertaining to Loss - Enter the location of the property prior to the loss or damage being reported.
Brief Description of Property Loss or Damage - Describe the property that was lost or damaged.
Cause of Loss - Enter the reason for the loss or damage.
Type of Insurance Coverage - Enter what type of insurance coverage is carried on the item that was lost or damaged.
Estimated Amount of Loss - Enter the cost or value of the item that was lost or damaged.
Replacement Value (Make the necessary adjustments to your property control records as required). - Use the value reported on the annual inventory report to the Comptroller's Office (CO-59).
Security - Adequate, Inadequate, None - Check the appropriate block depending on the level of security that was in place prior to the loss or damage.
What Steps Have Been Taken Within Your Agency To Prevent A Recurrence? Explain -
Give a brief statement of the action taken to prevent a recurrence.
Miscellaneous (If loss or damage was not reported immediately, indicate reason for delay) - Complete this section only if the loss or damage was not reported immediately or if there is additional information that should be disclosed.
Name of Individual to be Contacted Relative to Loss - Please provide the name of the individual that can respond if there are any questions by the Comptroller's Office or the Insurance Company of Record. It may not be the individual that prepared this report.
Telephone Number - Please provide a telephone number where the above named individual can be reached.
Authorized Signature -The authorized signature of the agency head.
Date - Enter the date that this report is submitted.
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