FES-1000AFORFF (1-16) ARIZONA DEPARTMENT OF ECONOMIC SECURITY

☐ Contract Inception

☐ Annual Inventory

☐ End-of-Contract Inventory

CONTRACTOR’S EQUIPMENT LIST

(Capital and Stewardship Equipment Items) Page ______ of ______

CONTRACTOR’S NAME(Legal name and DBA “doing businessas” 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

Item Description Manufacturer Serial No.

Acqu.

Date Physical Location

Total Item Cost

DES

Contract

Cost

EXHIBIT B

CONTRACTOR’S NAME(Printed) TITLE

CONTRACTOR’S SIGNATURE DATE SIGNED

DES CONTRACT NOTICES PERSON’S NAME(Printed) DES CONTRACT NOTICES PERSON’S SIGNATURE 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.

Thefollowingsectionsmustbecompletedbythecontractorwithin30daysofacquisitionofequipmentpurchasedwithcontractfundsandannuallythereafter 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(doingbusiness as)name.

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

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

INVENTORY DATE. Enter the date form is prepared.

ITEM DESCRIPTION. Enter the type of item and modelnumber.

ACQUISITION DATE. Enter the acquisition date ofpurchased equipment item.

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

TOTAL ITEM COST. Enter the total cost of the equipmentitem.

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

CONTRACTOR’S SIGNATURE. The individual delegatedauthority 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.

EqualOpportunityEmployer/Program•UnderTitlesVIandVIIoftheCivilRightsActof1964(TitleVI&VII),andtheAmericanswithDisabilitiesActof1990(ADA),Section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, and Title II of theGeneticInformationNondiscriminationAct(GINA)of2008;theDepartment prohibitsdiscriminationinadmissions,programs,services,activities,oremploymentbasedonrace,color,religion,sex,nationalorigin,age,disability,geneticsandretaliation.The Department must make areasonableaccommodationtoallowapersonwithadisabilitytotakepartinaprogram,serviceoractivity.Forexample,thismeansifnecessary,the Departmentmustprovidesignlanguageinterpretersforpeoplewhoaredeaf,awheelchairaccessiblelocation,orenlargedprintmaterials.ItalsomeansthattheDepartmentwill takeanyotherreasonableactionthatallowsyoutotakepartinandunderstandaprogramoractivity,includingmakingreasonablechangestoanactivity.Ifyoubelievethatyou willnotbeabletounderstandortakepartinaprogramoractivitybecauseofyourdisability,pleaseletusknowofyourdisabilityneedsinadvanceifatallpossible.Torequestthis document in alternativeformatorforfurtherinformationaboutthispolicy,contactyourlocaloffice;TTY/TDDServices:7-1-1.•FreelanguageassistanceforDESservicesis available upon request. • Ayuda gratuita con traducciones relacionadas con los servicios del DES está disponible a solicitud del cliente.