NORTH CENTRAL TEXAS TRAUMA REGIONAL ADVISORY COUNCIL HPP PROGRAM PROPERTY DISPOSITION REQUEST

Agency Name		
Address		
Point of Contact / Title		
Phone Number		Email Address		
PROPERTY DESCRIPTION
Property Description And Condition		
Property Location		
Serial Number		Tag Number		
Quantity		
HPP Contract Year			1		2		3		4		5		6		7		8		9		10	
			11		12		13		14		15		16		17		18		19		20	
Date Acquired		Hospital Disposition Log #		
Estimated Useful Life in Years	                          Years	HPP Funding %	           %	
Unit Acquisition Value	$	Expected Disposition Date		
PROPERTY DISPOSITION RECOMMENDATION
Desired Outcome (select as appropriate or provide details)		Transfer to Other Subrecipient		Trade in for Replacement Purchase	
		Dispose by Salvage		Dispose by Surplus	
	Other:	
SELECT AND INITIAL APPLICABLE STATEMENTS BELOW
	I attest that this asset is in serviceable condition if offered for transfer to another HPP subrecipient	
	I attest that this asset is no longer within estimated useful life	
	I attest that this asset no longer has value to the HPP Program	
	GC-11 with the requested assets highlighted is attached	
AGENCY ATTESTATION
Agency Authority Signature:		
Printed Signatory Name:		
Printed Signatory Title		
Date of Signature		
NCTTRAC RECOMMENDATION
NCTTRAC DISPOSITION LOG NUMBER:		
	Transfer to Other Subrecipient		Dispose by Surplus	
	Dispose by Salvage		Trade in for Replacement Purchase	
NCTTRAC / DSHS INSTRUCTIONS AND APPROVAL
	Transfer to Other Subrecipient		Dispose by Surplus	
	Dispose by Salvage		Trade in for Replacement Purchase	
NCTTRAC / DSHS Authority Signature:		
Printed Authority Name & Title		
Date of Signature		

PROGRAM PROPERTY DISPOSITION REQUEST

Form Instructions

Note: HIGHLIGHTED sections require hand written entries. Attach other documentation as required.	
		
Agency Name	Enter subrecipient name (required field)	
Address	Enter Street address, city, state, zip code (required field)	
Point of Contact / Title	Enter Agency representative name and title (required field)	
Phone Number	Enter Agency representative phone number (required field - NNN-NNN- NNNN)	
Email Address	Enter Agency representative email address (required field)	
Property Description And Condition	Enter Property description from GC-11 and condition (such as “beyond economical repair”, “like new”, etc. (required field)	
Property Location	Enter Address and storage location of equipment (required field)	
Serial Number	Enter Equipment serial number if capital or controlled equipment	
Tag Number	Enter Equipment tag number if capital or controlled equipment	
Quantity	Enter Number of units addressed by disposal request (required field)	
HPP Contract Year	Select the Check box for HPP year in which property was acquired (required field)	
Date Acquired	Enter Acquisition date from GC-11 or when received (required field - MM/YYYY)	
Estimated Useful Life in Years	Enter Estimated useful life from AHA or Texas State Property Accounting Users Guide, or manufacturer’s recommendation if guides do not reflect property in years (required field)	
Expected Disposition Date	Enter date asset disposition is expected to occur (MM/YYYY)	
HPP Funding %	Enter 100% if fully funded by HPP, or actual split percentage if non-HPP funds were used (required field)	
Unit Acquisition Value	Enter Original acquisition value (required field)	
Expected Disposition Date	Enter the date of desired disposition (MM/YYYY)	
Desired Outcome (select as appropriate or provide details)	Five options. Check appropriate box or write description in Other box: (1) Transfer to Other Subrecipient, (2) Dispose by Salvage, (3) Dispose by Surplus, (4) Trade in for Replacement Purchase, (5) Other – fill in details	

Select & initial	There are four statements required to be considered. Select the appropriate statements. Attest to statements by initialing associated block. Initial that GC-11 inventory is attached.	
Agency Authority Signature:	Signature required. Agency Point of Contact for HPP program or as desired by agency submitting request. (required field)	
Printed Signatory Name:	Printed name of agency signatory (required field)	
Printed Signatory Title	Printed title of agency signatory (required field)	
Date of Signature	Date of agency representative signature (required field – MM/DD/YYYY)	

Submit Program Property Disposition Requests by mail to: NCTTRAC Logistics
600 Six Flags Drive Suite 160
Arlington, TX 76011
Submission may be by fax to (817) 608-0399. Mark cover sheet for delivery to NCTTRAC Logistics. Email submission by special arrangement.  Contact NCTTRAC Logistics at (817) 608-0390.