SURPLUS PROPERTY NOMINATION FORM

CITY OF ANYTOWN, TENNESSEE

DEPARTMENT: __________________________________

The following items are hereby nominated for designation as surplus city property pursuant to

City Resolution No. __________________:

Item: _______________________________________________________________________

Description: __________________________________________________________________

Serial Number: _______________________________________________________________

Age: ___________    Asset #___________   Estimated remaining useful life (years)__________

Purchase price: Estimated Current Value:

Reasons for making the nomination: ______________________________________________

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Signature                                                                                           Date