Material Transfer Form Agencies that purchase or receive equipment with federal funding are required to maintain a Capital Asset/Equipment Inventory as per Code of Federal Regulations 44:13.32 and comply with federal audit regulations as per OMB Circular A-133, Audits of States, Local Governments, and Non-Profit Organizations. This form must be completed for equipment with a purchase price of $5,000 or above. For accountability purposes, this form and any attached equipment rosters are also used for material transfer of items with a purchase price of less than $5,000. The following equipment was purchased with federal funds under grant year ______ and the following grant fund: (circle one) UASI SHSGP EMPG PSIC CARES ACT The following equipment was purchased with general budget funds under fiscal year X and not grant funds. Equipment is being: Transferred Loaned Disposed/Surplus Missing Donated Transferring Entity Receiving Entity Riverside UASI Riverside Fire Department – OEM 3085 St Lawrence St Riverside, CA 92504 951-320-8103
Quantity Description of Item (include make and model) Serial No. Fair Market Value Additional Sheets or Equipment Rosters Attached? __Yes __ No Description of attachments: ______________________________ Receiving Entity agrees to all terms and conditions in the UASI Equipment Loan agreement dated _____________________________, which terms and conditions are incorporated herein by this reference. ____________________________________________________________________________________________________ Transferring Entity Representative Signature Printed Name Date ____________________________________________________________________________________________________ Receiving Entity Representative Signature Printed Name Date Acknowledge Return of Equipment ____________________________________________________________________________________________________ Transferring Entity Representative Signature Printed Name Date