+------------------------------------+--------------------+------------+
| **Custody Receipt for**            | U.S. Department of |            |
|                                    | Housing            |            |
| **Government Property**            |                    |            |
|                                    | and Urban          |            |
| **on Personal Charge**             | Development        |            |
|                                    |                    |            |
|                                    | Office of          |            |
|                                    | Administration     |            |
+------------------------------------+--------------------+------------+

  --------------------------- ------------ -------------------- ------------
  1\. Name of Chargeable      2\.          3\. Room No. and     7\. Custody
  Employee                    Telephone    Building             Receipt and
                              No.                               

  ----------                  ----------   ----------           Property
                                                                Pass Number

  4\. Organization Code       5\. Location 6\. Organization     ----------
                              Code         Symbol               

  ----------                  ----------   ----------           ----------
  --------------------------- ------------ -------------------- ------------

8\. Description of Property

  ----------------- ------------ ------------ --------------- ------------ ------------- ------------
  Type              Mfr.         Model        NSN/LN          Serial No.   Acquisition   

  ----------        ----------   ----------   ----------      ----------   Cost          Date

  ----------        ----------   ----------   ----------      ----------   ----------    ----------

  Type              Mfr.         Model        NSN/LN          Serial No.   Acquisition   

  ----------        ----------   ----------   ----------      ----------   Cost          Date

  ----------        ----------   ----------   ----------      ----------   ----------    ----------
  ----------------- ------------ ------------ --------------- ------------ ------------- ------------

Accessories, etc.

  -----------------------------------------------------------------------
  ----------

  ----------

  ----------

  ----------

  ----------

  ----------

  ----------

  ----------

  ----------

  ----------
  -----------------------------------------------------------------------

+-----------------------------------------------------------------------+
| 9.  Certificate of Receipt and Responsibility: I acknowledge          |
|     possession of the government property listed above. I accept full |
|     responsibility                                                    |
|                                                                       |
| for its use and safeguard. I am aware that I may not transfer the     |
| property except by return to or prior approval of the issuing office. |
| I                                                                     |
|                                                                       |
| further understand that should the property be lost, stolen or        |
| damaged through negligence or a willful act on my part, a Property    |
| Survey                                                                |
|                                                                       |
| Board may find me pecuniarily liable for restitution to the           |
| Government.                                                           |
+-----------------------------------------------------------------------+
| Signature of Chargeable Employee                                      |
+-----------------------------------------------------------------------+
| ----------                                                            |
+-----------------------------------------------------------------------+
| 10. Periodic Certification: I certify that as of the latest date      |
|     entered and initialed below, the item(s) listed heron is (are) in |
|     my custody; in                                                    |
|                                                                       |
| serviceable condition; and that I have a continuing need for use of   |
| the property.                                                         |
+-----------------------------------------------------------------------+

  ----- ------------ ------------ ---------- --- ------ ------------ ---------- ------------ ---------- --- ----- ------ ------------ --------- ------------ ----------
  FY-                                            FY-                                                        FY-                                              

  Qtr   Date                      Initials       Qtr                 Date                    Initials             Qtr                 Date                   Initials

  1     ----------   ----------              1          ----------              ----------              1                ----------             ----------   

  2     ----------   ----------              2          ----------              ----------              2                ----------             ----------   

  3     ----------   ----------              3          ----------              ----------              3                ----------             ----------   

  4     ----------   ----------              4          ----------              ----------              4                ----------             ----------   
  ----- ------------ ------------ ---------- --- ------ ------------ ---------- ------------ ---------- --- ----- ------ ------------ --------- ------------ ----------

  ------------ ------------ ------------ ------------ ------------ ------------ ------------ --------------
  11\. Issue   12\. By      13\. Return  14\.         15\.         16\. By      17\. Date    18\. Received
  Date                      Due          Follow-Up    Extended                  Return       by

  ----------   ----------   ----------   ----------   ----------   ----------   ----------   ----------
  ------------ ------------ ------------ ------------ ------------ ------------ ------------ --------------

Previous edition obsolete **HUD-26 (4-84)**

HB 2235.7