Attachment 18 - Example of a Certificate of Demilitarization.pdf

Tille: Certification of Demilitarization

A certification statement as shown shall be signed and dated by a DoD contracted person or a Government employee who actually performed or witnessed the DEMIL.

Description: The certificate shall be verified by a technically qualified DoD contracted person or a Government employee who witnessed the DEMIL of the material or inspected the residue. The individual who verifies the DEMIL should generally be at least in the next higher management or technical level to the initial certifying individual and must be a U.S. citizen.

Disposal Turn-In Document: l QTY:

National Stock Number or Description:

Certification Statement:

I CERTIFY THAT THE ITEMS(S) LISTED HEREON HAS/HAVE BEEN DEMILITARIZED IN

ACCORDANCE WITH DoD MANUAL 4160.28, VOLUME 3, "DEFENSE DEMILITARIZATION:

PROCEDURAL GUIDANCE," CATEGORY PARAGRAPH AND/OR THE

FOLLOWING APPLICABLE REGULATION:

Signature (Certifier): Date

Printed Name/Grade/Rank:

Title:

Phone (COM/DSN/FAX):

Address:

Signature (Verifier): Date

Printed Name/Grade/Rank:

Title:

Phone (COM/DSN/FAX):

Address:

Reference:

DoD Manual 4160.28, Volume 3, "Defense Demilitarization:

Procedural Guidance," Change 1, 02/09/2018

Attachment 18 - Example of a Certificate of Demilitarization

SP4500-19-R-0000

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