Attachment_J-11_HHS_Form_565_Report_of_Accountable_Personal_Property_Template.doc

Attachment J-11 HHS Form 565 Report for Accountable Personal Property Template

DEPARTMENT OF HEALTH AND HUMAN SERVICES

REPORT OF ACCOUNTABLE PERSONAL PROPERTY

NOTE: Complete this form in accordance with instructions on reverse side of copy No. 1.

OMB No. 0990-0015 Expiration Date: 12/31/99

1. DATE

2. PUBLIC VOUCHER NO.

3. CONTRACT NUMBER

4. REPORT NO.

PAGE NO.

NO. PAGES

5. NAME OF PERSON RESPONSIBLE FOR THIS REPORT

TELEPHONE: AREA CODE NO.

6. TYPE OF REPORT ACQUISITION - GOV. TITLED ACQUISITION - CONTR. TITLED

ANNUAL INVENTORY FINAL INVENTORY

7. NAME AND ADDRESS OF CONTRACTOR

8.

FOR GOV USE ONLY

9.

ITEM

NO.

10.

DESCRIPTION & NSN

11.

GFP

OR CAP

12.

MFR.

13.

MODEL OR

TYPE

14.

MFR. SERIAL

NO.

15.

UNIT ACQUISITION

COST

16.

GOV

ID NO.

17. ACQ. AUTH.

18. DATE REC’D. MO/YR

19. AUTHORIZATION BY CONTRACTOR’S SUPERVISORY ACCOUNTING OFFICIAL

20.

ACCEPTED BY AUTHORIZATION GOVERNMENT

REPRESENTATIVE

VOUCHER NO.

SIGNATURE DATE

SIGNATURE AND TITLE

DATE

NAME (TYPED) TITLE

HHS 565 (9/98) Created by Electronic Document Services/USDHHS: (301) 443-2454 EF AttachmIeNnSt JT-R11UHCHTSIOFNoSrmF5O6R5 RPeRpEorPt AfoRr AATccIOouNntOabFleHPHerSsoFnaOl RPMrop5e6rt5y Template

REPORT OF ACCOUNTABLE PERSONAL PROPERTY

This report shall be submitted in an original and 2 copies by the contractor and included with his Public Voucher (or invoice) under which reimbursement for the acquisition of authorized accountable personal property is requested. When utilizing this form for inventory reporting, two copies shall be forwarded to the cognizant Property Administrator. Final inventories must include the Certification required by HHS Contractor’s Guide for Control of Government Property.

Item No.

1. Enter date prepared.

2. Enter Public Voucher (or Invoice) Number.

3. Enter complete contract number.

4. Enter number of this report. (Reports will be numbered serially beginning with No. 1 for each contract.) Enter page number of pages.

5. Enter name and telephone number of contractor’s representative responsible for report.

6. Indicate type of Report.

7. Enter name and address of contractor exactly as it appears on the contract.

8. Leave blank. For Contracting Agency use only.

9. Enter line item number. Each report shall begin with number "1".

16. For Government owned property, enter the Government identification number (decal) affixed. For Contractor owned property, enter contractor’s identification number affixed.

17. Enter authorization for acquisition e.g., contract schedule number, contracting officer’s authorization letter number, etc.

18. Enter month and year property was received by contractor as reflected on receiving report.

19. Enter signature and title of person authorized to certify to the accuracy of report.

20. Leave blank. For Contracting Agency use only.

This Form may be reproduced by Contractors in size 8-1/2" X 11" only.

Burden Estimate Statement A federal agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Public reporting burden for this collection of information is estimated to vary from thirty (30) minutes to one hour per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the necessary data, and completing and reviewing the collection of information. Send comments regarding the burden of estimate or any other aspect of this collection of information to the OS Reports Clearance Officer, ASMB/Budget/DIOR, Room 503H, HHH Building, 200 Independence Avenue, S.W., Washington, D.C. 20201.