UNIVERSITY OF PITTSBURGH FORM INSTRUCTION GUIDE FORM TITLE: ASSET RETIREMENT NUMBER: FORM 0093 PROCEDURE: 05-10-01 DATE: January 24, 2005 Revised REMOVE AND ATTACH ASSET TAG TO THE UPPER RIGHT CORNER OF THE ASSET RETIREMENT FORM. TO BE COMPLETED BY THE DEPARTMENT RETIRING THE EQUIPMENT: 1. Three digit Building Code of the building where the asset was located. 2. Room number where asset is located. 3. Asset tag number that uniquely identifies each asset. The field must always contain eight characters. 4. Brief description of the asset. 5. Serial number assigned by manufacturer. 6. Purchase Order number of asset, if known. 7. Five digit department number. 8. Circle Y (Yes) or N (No) to indicate if asset contains or was used near a hazardous substance. If yes, identify substance and attach a copy of Material Safety Data Sheet. 9. Circle Y (Yes) or N (No) to indicate if accessories are being retired along with the asset. 10. Signature, Date, and Campus extension of preparer. COMPLETE FOR PI TRANSFER ONLY: 11. Name of institution, and address, where the asset is transferring to. COMPLETE FOR SOLD, SCRAPPED, OR DONATED ASSETS ONLY: 12. Dollar amount of proceeds from sale of asset, if applicable. Attach a copy of the Cash Report, if applicable. Name of party acquiring asset. COMPLETE FOR TRADED ASSETS ONLY: 13. Trade-in value of asset. Purchase Order number of asset acquired in trade. Name of requisitioner. COMPLETE FOR LOSSES OR THEFT ONLY: 14. Name of Officer investigating theft. Circle Y (Yes) or N (No) to indicate whether asset is insured. Attach a copy of the campus police report, if applicable. FOR FINANCIAL RECORDS SERVICES ONLY: 15. Code of asset disposition method. 16. Asset acquisition date. 17. Life of asset in months. 18. Acquisition cost, Depreciation, and Net Book Value of asset. 19. Disposition date. 20. Research Accounting Authorization, if applicable. 21. Signature of Asset Management preparer and processor and date.