FINANCIAL LIABILITY INVESTIGATION OF PROPERTY LOSS …
[Pages:2]FINANCIAL LIABILITY INVESTIGATION OF PROPERTY LOSS
PRIVACY ACT STATEMENT
AUTHORITY: 10 USC 2775; DoD Directive 7200.11; EO 9397.
ROUTINE USE(S): None.
PRINCIPAL PURPOSE(S): To officially report the facts and circumstances supporting the assessment of financial charges for the loss, damage, or destruction of DoD-controlled property. The purpose of soliciting the SSN is for positive identification.
DISCLOSURE: Voluntary; however, refusal to explain the circumstances under which the property was lost, damaged, or destroyed may be considered with other factors in determining if an individual will be held financially liable.
1. DATE INITIATED (YYYYMMDD)
2. INQUIRY/INVESTIGATION NUMBER
3. DATE LOSS DISCOVERED (YYYYMMDD)
4. NATIONAL STOCK NO. 5. ITEM DESCRIPTION
6. QUANTITY 7. UNIT COST 8. TOTAL COST
0.00
9. CIRCUMSTANCES UNDER WHICH PROPERTY WAS (X one) (Attach additional pages as necessary)
LOST
DAMAGED
DESTROYED
10. ACTIONS TAKEN TO CORRECT CIRCUMSTANCES REPORTED IN BLOCK 9 AND PREVENT FUTURE OCCURRENCES (Attach additional pages as necessary)
11. INDIVIDUAL COMPLETING BLOCKS 1 THROUGH 10 a. ORGANIZATIONAL ADDRESS (Unit Designation, b. TYPED NAME (Last, First, Middle Initial) Office Symbol, Base, State/Country, Zip Code)
d. SIGNATURE
c. DSN NUMBER e. DATE SIGNED
12. (X one)
RESPONSIBLE OFFICER (PROPERTY RECORD ITEMS)
a. NEGLIGENCE OR
b. COMMENTS/RECOMMENDATIONS
ABUSE EVIDENT/ SUSPECTED (X one)
REVIEWING AUTHORITY (SUPPLY SYSTEM STOCKS)
YES
NO
c. ORGANIZATIONAL ADDRESS (Unit Designation, d. TYPED NAME (Last, First, Middle Initial) Office Symbol, Base, State/Country, Zip Code)
e. DSN NUMBER
f. SIGNATURE
g. DATE SIGNED
13. APPOINTING AUTHORITY
a. RECOMMENDATION (X one)
b. COMMENTS/RATIONALE
APPROVE
DISAPPROVE d. ORGANIZATIONAL ADDRESS (Unit Designation,
Office Symbol, Base, State/Country, Zip Code)
e. TYPED NAME (Last, First, Middle Initial)
g. SIGNATURE
c. FINANCIAL LIABILITY
OFFICER APPOINTED (X one)
YES
NO
f. DSN NUMBER
h. DATE SIGNED
14. APPROVING AUTHORITY
a. RECOMMENDATION (X one)
b. COMMENTS/RATIONALE
APPROVE
DISAPPROVE d. ORGANIZATIONAL ADDRESS (Unit Designation,
Office Symbol, Base, State/Country, Zip Code)
e. TYPED NAME (Last, First, Middle Initial)
g. SIGNATURE
c. LEGAL REVIEW
COMPLETED IF REQUIRED (X one)
YES
NO
N/A
f. DSN NUMBER
h. DATE SIGNED
DD FORM 200, OCT 1999
PREVIOUS EDITION IS OBSOLETE.
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15. FINANCIAL LIABILITY OFFICER a. FINDINGS AND RECOMMENDATIONS (Attach additional pages as necessary)
b. DOLLAR AMOUNT OF LOSS
c. MONTHLY BASIC PAY
d. RECOMMENDED FINANCIAL LIABILITY
e. ORGANIZATIONAL ADDRESS (Unit Designation, f. TYPED NAME (Last, First, Middle Initial) Office Symbol, Base, State/Country, Zip Code)
h. DATE REPORT SUBMITTED TO APPOINTING AUTHORITY (YYYYMMDD)
j. SIGNATURE
g. DSN NUMBER
i. DATE APPOINTED
(YYYYMMDD)
k. DATE SIGNED
16. INDIVIDUAL CHARGED a. I HAVE EXAMINED THE FINDINGS AND RECOMMENDATIONS OF THE FINANCIAL LIABILITY OFFICER AND (X one)
Submit the attached statement of objection.
Do not intend to make such a statement.
b. I HAVE BEEN INFORMED OF MY RIGHT TO LEGAL ADVICE. MY SIGNATURE IS NOT AN ADMISSION OF LIABILITY.
c. ORGANIZATIONAL ADDRESS (Unit Designation, d. TYPED NAME (Last, First, Middle Initial)
e. SOCIAL SECURITY
Office Symbol, Base, State/Country, Zip Code)
NUMBER
f. DSN NUMBER
g. SIGNATURE
17. ACCOUNTABLE OFFICER a. DOCUMENT NUMBER(S) USED TO ADJUST PROPERTY RECORD
b. ORGANIZATIONAL ADDRESS (Unit Designation, c. TYPED NAME (Last, First, Middle Initial) Office Symbol, Base, State/Country, Zip Code) e. SIGNATURE
h. DATE SIGNED
d. DSN NUMBER f. DATE SIGNED
DD FORM 200 (BACK), OCT 1999
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