SMW.pdf

SURPLUS MATERIEL WORKSHEET

DATE

03 SEP 2019

I. REQUEST FOR EVALUATION

NSN

4810000073455GA

PART NUMBER

212-076-006-5

CAGE

97499

APPLICATION

UH-1N

IMS

Nanez, Doug A

OFFICE SYMBOL

AFLCMC / WLSEAB

PHONE

478-926-4836

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

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

Y X X X X

Y X X

N

N

Y X X X

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 MFG 97499 P/N 212-076-006-5

PRIOR GOVERNMENT OWNERSHIP

100% END ITEM INSPECTION

TEST AND VERIFICATION TECH ORDER NUMBER

VERIFIABLE DIMENSION DESIGN ACTIVITY 97499

DRAWING NUMBER 212-076-006

LOCATION OF INSPECTION TESTING

ITEMS WILL BE TESTED FOR INITIAL ACCEPTANCEINITIAL ACCEPTABILITY ITEMS A QUANTITY OF

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

OVERHAUL AND CERTIFICATION

Item shall have been overhauled by a FAA certified repair station in accordance with the manufacturer's instructions and shall be delivered with an authorized FAA Form 8130-3 airworthiness approval tag.

OTHER SPECIAL REQUIREMENTS (Explain)

McHaffey, Jeanette MNAME: 07 MAR 2017DATE:

New and unused surplus material in original packaging and manufactured by an approved source (CAGE 97499, 05228, or 81873) is acceptable. All items must be traceable to approved source. 100% end item inspection for condition.

REMARKS

JUSTIFICATION FOR UNACCEPTABLE SURPLUS MATERIEL

Only items manufactured by an approved source and listed on the applicable Bell Helicopter Qualified Products Listing have satisfactorily passed qualification testing and are acceptable.

EVALUATOR

Nanez, Doug A

OFFICE SYMBOL

AFLCMC / WLSEAB

PHONE

478-926-4836 / 468-4836

COMPLETE DATE

03 SEP 2019

SIGNATURE

//SIGNED// Nanez, Doug A

USER TYPE

Engineer

SIGNATURE DATE

03 SEP 2019

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