Office of Property and Materials Management
                                                                        INVENTORY CONTROL

                    RECORD OF GIFTS AND DONATIONS TO UCONN HEALTH CENTER - IC 1

DATE: _____/_____/_____

DEPARTMENT: _____________________________________________________________________

Contact Person: _______________________________________ Tel. No. _____________________

ACQUIRED FROM: ( Donor )

Name _____________________________________________________________________________

Institution / Company ________________________________________________________________

___________________________________________________________________________________

City ________________________________ State _________ Zip _________ Tel. No. ____________

COMPLETE THE FOLLOWING INFORMATION FOR GIFT / DONATION:

Description _________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

Make: _____________________________________________ Model: _________________________

Serial Number: ______________________________________ Color: __________________________
Size: ______________________________________________ Quantity: _______________________

Other Pertinent Information: __________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

Date Acquired _____/_____/_____

Value ___________________          Appraised Value  ($5,000 or more)  ________________________

Location __________________________________________ Estimated Life ____________________

NOTE: Item (s) become Institutional Property and Will Not Be Available for Transfer Outside the
Health Center.
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APPRAISAL INFORMATION: ( Copy of Certified Appraisal Must Be Attached)
(Only for Items with a value of $5,000 or more)

Name of Appraiser ___________________________________________________________________

Appraisal Company __________________________________________________________________

City __________________________ State __________ Zip _________ Tel. No. _________________

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SIGNATURES: ( Signatures Must Be In Order Stated Below)

___________________________  _____/_____/_____         ___________________________  _____/_____/_____
(1) Department Head                             Date                                      (2) Dean (If Applies)                             Date

___________________________  _____/_____/_____        ___________________________  _____/_____/_____
(3) AVP for Development                     Date                                     (4) Director of  Materials Management                 Date


INCLUDE A COPY OF RELEVANT DOCUMENTS.

cc: UConn Foundation,  Insurance Administrator (Purchasing)