Surplus Request Form

Please Note: SWAP only picks up items from UW Departments and Local State Agencies
See Purchasing Policy and Procedures #18 for further information

Is this a Pick-Up or a Drop-Off? Pick-Up Drop-Off (Please submit this form at least 24 hours before dropping off your items) Online Auction - Items on Location
Please complete all information below or your form will not be processed.
Contact Name:
Phone number:
E-mail:
Department:
Building Name/Street Address and Room Number:
Location of items (if different from above):
MDS Account Number: (required)
The University can only return the net proceeds from the sale of these items to your department if the following statement is true: The assets being sold were originally purchased with grant or gift funds, OR the assets being sold are being replaced, OR they have recently been replaced, OR the functionality has been replaced. True False

Description of Equipment

Qty.	Description of Equipment	Description of Equipment Condition	Mfr's Serial / UW Inventory Number	Suggested Current Value	Originally 144 Funds (Y/N)	Funding String (144 Funds Only)
					No Yes
					No Yes
					No Yes
					No Yes
					No Yes
					No Yes
					No Yes
					No Yes
					No Yes
					No Yes
					No Yes
					No Yes

Additional Comments:

I understand that:

I am fully responsible for identifying each asset purchased with grant or gift money.
I am required to provide any University of Wisconsin asset decal numbers, equipment serial numbers, and ALL FEDERAL IDENTIFICATION numbers regardless of the original purchase price.
144-funded items should be stored in a secure area before pick-up and will not be picked up until released by Research and Sponsored Programs (RSP)
Any potential funds returned to the department that have been sold through Surplus With A Purpose (SWAP) are the responsibility of the department to determine where those funds are to ultimately be returned to.

*If you checked "Yes" stating that an item was originally purchased with 144 funds, you must provide the funding string for that item.

Please print a copy of this form for your records and press SUBMIT.