State of Wisconsin

Department of Administration

Division of State Agency Services

DOA-6740 (C04/2001)

Please return to:

Risk Management

21 N. Park Street, Suite 6101

Madison, WI 53715

FAX 608-262-9082

Lightning Losses Affidavit

Date

To Risk Management: ____________________________________________________________________________________

I inspected and/or repaired this damaged item:

Model Number:

Serial Number:

Year/Model:

Date of Purchase:

Purchase Price:

Size?

Place Purchased:

Owned by (Dept name):

Campus Address:

Date of Loss:

Time of Loss:

Are damaged item(s) available for inspection? Where?

If not, why?

This damage was solely due to lightning and no other cause whatever because:

Signature of Repair Person
Print Name of Repair Person
Firm Name
Firm Address (Street, City & State)