813.pdf

SURPLUS MATERIEL WORKSHEET

DATE

06 DEC 2016

I. REQUEST FOR EVALUATION

NSN

1615009181912GA

PART NUMBER

204-040-324-005

CAGE

97499

APPLICATION

TH-1H Helicopters

IMS

McHaffey, Jeanette M

OFFICE SYMBOL

AFLCMC / WIUEC

PHONE

478-327-6968

SURPLUS MATERIEL MAY BE AVAILABLE TO FULFILL THE GOVERNMENT'S NEEDS FOR THIS ITEM. AS A RESULT, AN EVALUATION MUST BE PERFORMED

IAW AFMC FAR SUPPLEMENT PART 5352.

THE EVALUATION ON THIS ITEM INDICATES SURPLUS MATERIEL WILL BE CONSIDERED IN THE FOLLOWING TYPES / CATEGORIES

II. EVALUATION CRITERIA (For types/categories deemed acceptable)

ACCEPT-

ABLE (Y/N)

P/N AND

MFG

VERIFI-

CATION

PRIOR

GOV'T

OWNER-

SHIP

100% END

ITEM

INSPECT

TEST AND

VERIFI-

CATION

VERIFI-

ABLE

DIMEN-

SIONS

LOCATION

INSPEC-

TION

TESTING

INITIAL

ACCEPT-

ABILITY

ITEMS

OVERHAUL

AND

CERTIFI-

CATION

OTHER

(Explain in Remarks)

Y X X X

N

N

N

Y X X

N

N

N

G O V T

S U R P L U S

NEW/UNUSED

NEW/RECONDITIONED

NEW/MODIFIED

USED/OVERHAULED

C O M M L

S U R P L U S

NEW/UNUSED

NEW/RECONDITIONED

NEW/MODIFIED

USED/OVERHAULED

SURPLUS EVALUATION CRITERIA (If Section 11a. indicates surplus materiel may be considered). (Fill in blanks as appropriate)

PART NUMBER VERIFICATION 97499(AFMCFARS 5352.211-9011) MFG 204-040-324-5P/N

PRIOR GOVERNMENT OWNERSHIP (AFMCFARS 5352.211-9015)

100% END ITEM INSPECTION (AFMCFARS 5352.211-9017)

TEST AND VERIFICATION (AFMCFARS 5352.211-9013) TECH ORDER NUMBER

VERIFIABLE DIMENSION (AFMCFARS 5352.211-9012) DESIGN ACTIVITY

DRAWING NUMBER

LOCATION OF INSPECTION TESTING (AFMCFARS 5352.211-9015)

INITIAL ACCEPTABILITY ITEMS (AFMCFARS 5352.211-9014) A QUANTITY OF ITEMS WILL BE TESTED FOR INITIAL ACCEPTANCE

TEST WILL BE CONDUCTED USING THE FOLLOWING CRITERIA (and location of testing)

OVERHAUL AND CERTIFICATION (AFMCFARS 5352.211-9010)

OTHER SPECIAL REQUIREMENTS (Explain)

McHaffey, Jeanette MNAME: 25 FEB 2015DATE:

New and unused surplus material in original packaging and manufactured by approved source CAGE 97499 is acceptable. All items must be traceable to approved source. 100% end item inspection for condition.

REMARKS

JUSTIFICATION FOR UNACCEPTABLE SURPLUS MATERIEL

This part is an aviation critical safety item and requires engineering source approval in order to maintain the quality of the part. Only CAGE 97499 is an approved source.

EVALUATOR

McHaffey, Jeanette M

OFFICE SYMBOL

AFLCMC / WIUEC

PHONE

478-327-6968 / 497-6968

COMPLETE DATE

06 DEC 2016

SIGNATURE

//SIGNED// McHaffey, Jeanette M

USER TYPE

Engineer

SIGNATURE DATE

06 DEC 2016

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