Form GSA Form 3040 GSA Form 3040 State Agency Monthly Donation Report of Surplus Personal

STATE AGENCY MONTHLY DONATION
REPORT OF SUPRLUS PERSONAL PROPERTY

DATE (Month and year)

OMB Control Number: 3090-0112
Expiration Date: 1/31/2019

Paperwork Reduction Act Statement - This information collection meets the requirements of 44 U.S.C. § 3507, as amended
by section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these questions unless we display a valid
Office of Management and Budget (OMB) control number. The OMB control number for this collection is 3090-0112. We
estimate that it will take 90 minutes to read the instructions, gather the facts, and answer the questions. Send only comments
relating to our time estimate, including suggestions for reducing this burden, or any other aspects of this collection of
information to: U.S. General Services Administration, Regulatory Secretariat Division (M1V1CB), 1800 F Street, NW,
Washington, DC 20405.
TO

FROM (Give name of Reporting State Agency)

ACQUISITION COST (Omit cents)
SUBTOTAL
TOTAL

DESCRIPTION OF ITEMS
A. BEGINNING INVENTORY

$

B. PROPERTY RECEIVED
1. From Federal Agencies

$

2. From other State Agencies

$

3. From overseas

$

4. Other receipts

$

5. TOTAL

$

C. PROPERTY DONATED

1. PUBLIC
AGENCIES

a. Conservation

$

b. Economic development

$

c. Education

$

d. Parks and recreation

$

e. Public health

$

f. Public safety

$

g. Two or more of the above

$

h. Other

$

i. TOTAL OF PART 1

$

a. Education

$

2. NONPROFIT
b. Public health
INSTITUTIONS
OR
ORGANIZATIONS c. TOTAL OF PART 2
GRAND TOTAL OF PARTS 1 AND 2

GENERAL SERVICES ADMINISTRATION

$
$
$

GSA 3040 (REV. 11/2015)

D. OTHER DISTRIBUTION
1. Transfer to other State Agencies

$

2. Return to Federal Agency

$

3. Sold

$

4. Abandoned or destroyed

$

5. Other adjustments

$

6. TOTAL

$

E. ENDING INVENTORY

$

ACQUISITION COST (Omit cents)
SUBTOTAL
TOTAL

DESCRIPTION OF ITEMS
E. METHOD OF DISTRIBUTION
1. From State Agency facility

$

2. Direct from holding agency

$

3. TOTAL

$

F. DISTRIBUTION TO PUBLIC AGENCIES
1. State

$

2. Local

$

3. TOTAL

$

REMARKS (Continue on separate sheet, if necessary)

TYPED NAME AND TITLE OF APPROVING OFFICIAL

GENERAL SERVICES ADMINISTRATION

SIGNATURE OF APPROVING OFFICIAL

DATE

GSA 3040 (REV. 11/2015) BACK