Exhibit_A_-_Contractor_s_Equipment_List.doc

FES-1000AFORFF (1-16)

ARIZONA DEPARTMENT OF ECONOMIC SECURITY

FORMCHECKBOX

Contract Inception

FORMCHECKBOX

Annual Inventory

FORMCHECKBOX

End-of-Contract Inventory

CONTRACTOR’S EQUIPMENT LIST

(Capital and Stewardship Equipment Items) Page ______ of ______

CONTRACTOR’S NAME (Legal name and DBA “doing business as” name)

FEI/SSN

MAILING ADDRESS (P.O. Box or No., Street, City, State, ZIP)

PHONE NO.

DES CONTRACT NO.

CONTRACT BEGIN DATE

CONTRACT END DATE

INVENTORY DATE

Date

Item Cost

DES

Contract Cost

CONTRACTOR’S NAME (Printed)

TITLE

CONTRACTOR’S SIGNATURE

Original Signature Required!

DATE SIGNED

DES CONTRACT NOTICES PERSON’S NAME (Printed)

DES CONTRACT NOTICES PERSON’S SIGNATURE

Original Signature Required!

PHONE NO.

DES PROGRAM

MAIL DROP

DATE SIGNED

See reverse for EOE/ADA/LEP/GINA disclosures.

Completion Instructions for FES-1000AFORFF

CONTRACTOR’S EQUIPMENT LIST

(Capital and Stewardship Equipment Items)

A. Purpose.

To facilitate the inventory control of capital and stewardship equipment purchased with Department contract funds.

B. Completion.

The following sections must be completed by the contractor within 30 days of acquisition of equipment purchased with contract funds and annually thereafter until the contract’s termination. At the contract’s conclusion date, an end-of-contract inventory is completed. ALL INFORMATION IS TO BE TYPED.

All items are self-explanatory except:

CONTRACTOR’S NAME. Enter legal name and DBA (doing business as) name.

FEI OR SSN. Enter the federal employer identification number or social security number as applicable.

DES CONTRACT NO. Enter the contract number through which the equipment was purchased or acquired.

INVENTORY DATE. Enter the date form is prepared.

ITEM DESCRIPTION. Enter the type of item and model number.

ACQUISITION DATE. Enter the acquisition date of purchased equipment item.

PHYSICAL LOCATION. Enter the address where the equipment is located. Do not use a “P.O. Box” designation.

TOTAL ITEM COST. Enter the total cost of the equipment item.

DES CONTRACT COST. Enter the amount of contract funds used to acquire the item.

CONTRACTOR’S SIGNATURE. The individual delegated authority for the inventory control must sign the form.

Shaded area is to be completed by DES staff.

C. Routing.

The contractor submits the form to the DES Program Division/Administration Contract Unit within 30 days of the acquisition of the item and annually thereafter.

Equal Opportunity Employer/Program • Under Titles VI and VII of the Civil Rights Act of 1964 (Title VI & VII), and the Americans with Disabilities Act of 1990 (ADA), Section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, and Title II of the Genetic Information Nondiscrimination Act (GINA) of 2008; the Department prohibits discrimination in admissions, programs, services, activities, or employment based on race, color, religion, sex, national origin, age, disability, genetics and retaliation. The Department must make a reasonable accommodation to allow a person with a disability to take part in a program, service or activity. For example, this means if necessary, the Department must provide sign language interpreters for people who are deaf, a wheelchair accessible location, or enlarged print materials. It also means that the Department will take any other reasonable action that allows you to take part in and understand a program or activity, including making reasonable changes to an activity. If you believe that you will not be able to understand or take part in a program or activity because of your disability, please let us know of your disability needs in advance if at all possible. To request this document in alternative format or for further information about this policy, contact your local office; TTY/TDD Services: 7-1-1. • Free language assistance for DES services is available upon request. • Ayuda gratuita con traducciones relacionadas con los servicios del DES está disponible a solicitud del cliente.