uchc_logo.gif (10775 bytes)
                                                                  

 OFFICE OF PROPERTY & MATERIALS MANAGEMENT

INVENTORY CONTROL

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

 

UNIVERSITY OF CONNECTICUT ART COMMITTEE Date: ____/____/____

Chairperson: ______________________________________ Tel. No. ( ____ )-______-_________

ACQUIRED FROM: (DONOR)

Name _____________________________________________________________________________

Institution / Company ________________________________________________________________

___________________________________________________________________________________

City ____________________ State ________ Zip __________ Tel. No. ( _____)-_______-_________

COMPLETE THE FOLLOWING INFORMATION FOR GIFT / DONATION OF ART:

Name of Artist _____________________________________________________________________

Description _________________________________________________________________________

Title (If Applies) ____________________________________________________________________

Type of Art Work _______________________________________________(Painting, Sculpture etc.)

Other Pertinent Information: ___________________________________________________________

Value: _____________________     Appraised Value: (If $5,000 or more) ______________________

Does Donation Include Copyright Privileges:       Yes: No: Fine Art: Decorative Art:

If "Yes", please include supporting documentation.
Date Accepted __/__/__ Date Received __/__/__ Condition _______ Appraised Value ___________

Location to be displayed_______________________________________________________________

Asset Number(s) ____________________________________________________________________

NOTE: Item (s) Become Institutional Property and Will Not Be Available for Transfer Outside the

Health Center.

------------------------------------------------------------------------------------------------------------------

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. ( ____ )-______-_____

--------------------------------------------------------------------------------------------------------------------------------

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.

Once Fully Executed:

cc: UConn Foundation,  Insurance Administrator (Purchasing)