CRS COMMODITY LOSS AND CLAIM PURSUIT REPORT

TO: DATE :
FROM: CRS <<COUNTRY PROGRAM>> LOSS REPORT No:
WHSE: CLAIM No :
VENDOR: DISTRIBUTION CENTER:
TRANSPORTER CENTER CODE:

Regular Program
● Food Commodities
Non-Food Commodities Other:

Containers
Source Total QTY Value CIF per Loss Value
Commodity DN / WB No. (e.g., Supplier, Lost by Weight KG or Unit CIF
(provide specifications) No. of
Type of Net Weight in Donor) (in KG) or Unit (US $) (US $)
Damaged
Container KG
Containers

$0.00
0.00 $0.00
0.00 $0.00
0.00 $0.00
0.00 $0.00
0.00 $0.00
TOTALS : 0.00 $0.00

3. Time and place of loss / damage / misuse:

4. Current location or disposition of commodities:

5. Person or agency having possession of commodities at time of loss / damage / misuse:

6. Nature and extent of loss / damage / misuse:

7. Details and circumstances under which loss / damage / misuse took place:

8. Actions taken to effect recovery, disposal (e.g., sale, donation, destruction) or restitution:

9. Details of any claims established against parties liable for the loss / damage / misuse:

10. CRS proposes to waive further claims collection because:

Signature (CRS) : Date:

ACTION: CRS or Donor Official

Concurs with the PVO action(s) taken.

Does not concur (explain):

Claim should be made against:

Other recommendations:

Signature (Authorized Official): Date: