Master_228_Fire_Dept.pdf

FURNISHINGS CUSTODY RECEIPT AND CONDITION REPORT

(This form is subject to the Privacy Act of 1974 - See reverse)

Read instructions on the back of this form before completing.

CONDITION CODES (For columns D, F, and H) BE-Bent FA-Faded RU-Rusted CG-Chipped LO-Loose

TR-Torn

BR-Broken GG-Gouged SC-Scratched DE-Dented MA-Marred

N am e

NO. OF BEDROOMS NO. IN FAMILY SIGNATURES

I hereby designate the individual named below as authorized to receipt for property.

(Typed Name of Occupant)

(Signature of Occupant)

Gra de

(Signature of Sponsor) Sign& Date

ITEM

DESCRIPTION

A

STOCK NO.

B

ISS.

c

COND D ISS.

E

COND

F

ISS.

G

COND

H

TURN

IN

I

BAL

J

SSN

24” LED/DVD HDTV 29

60” TV 2

Bedframe w/Rollers 29

Bookcase, 4 Shelf 1 O r ganiz ati on

Box Spring & Mattress 29

Desk 42” X 24” 28

Fan, Tower, Black 28

Headboard, Twin 29

Nightstand w/o Drawers 28

Recliner 14

Table 1

Task chair 29

TV Wall Mount 29

Wall System 2

D uty

722-

P hones

AF FORM 228, 20001101 (EF-V1)

PRIVACY ACT STATEMENT

AUTHORITY: 10 USC 8012; 10 USC 9832; 10 USC 9837 and 10 USC 9840.

PRINCIPAL PURPOSES: To provide issuing offices a custody receipt for both housekeeping and non-housekeeping quarters furnishings and equipment issued to authorized customers.

ROUTINE USE(S): SSN is used for positive identification.

DISCLOSURE: Providing your SSN Is voluntary. Some of the information in this form is privileged and cannot be disclosed without your consent You are not required to complete this form, but failure to do so may result in the denial of furnishings and equipment.

INSTRUCTIONS

1. AF Form 228 will be completed in duplicate by the occupant and the issuing office representative, the original being retained by the issuing office.

2. Upon termination of the quarters occupancy or upon turning in any item, all Government furnished property must be essentially in the same condition as issued, except for deterioration deemed to be fair wear and tear.

3. Each transaction for the receipt of property must be acknowledged by signature of the sponsor or authorized representative. Each turn-in transaction must be acknowledged by signature of the issuing office representative.

4. Item condition remarks, if any, win be recorded in the space below.

5. When deemed necessary, descriptions and stock numbers of items commonly issued may be locally overprinted on this form.

6. Personnel signing AF Form 228 for furnishings will be held responsible in accordance with AF132-6004, Accounting and Reporting of Government Property Lost, Damaged, or Destroyed, for loss or damage (other than fair wear and tear) of all items in their custody.

7. Furnishings will not be removed from or exchanged between quarters unless approved by the issuing office.

8. Upon termination of quarters, all personnel must clear their account with the issuing office. If loss or damage exists, AFI32-6004, will be used to reconcile the discrepancy.

9. Columnar Use:

Column A - Self-explanatory Column B - Self-explanatory Column C - Number of items issued and occupant's signature.

Column D - Condition code of item Columns E-H - Used for the subsequent issues of the same item or different items (so that the initials and date will reflect the _ separate issue).

Column I - Number of iterns turned in and issuing office representative's signature and date.

Column J - Current balance in occupant's quarters.

REMARKS

SEAN M. QUINBY, DAF, USAF

Chief, Fire Emergency Services Flight

AF FORM 228, 20001101 (EF-V1)