REPORT OF ACCOUNTABILITY FOR ACCOUNTABLE FORMS

_________________________________________________
Agency
Month of ______________________________, 20____

Accountable Forms Beginning Balance Receipt Issuance Ending Balance

Face Inclusive Serial Nos Inclusive Serial Nos Inclusive Serial Nos Inclusive Serial Nos.
Name of Form Number Qty. Qty. Qty. Qty.
Value From To From To From To From To
A. WITH FACE VALUE
143

B. WITHOUT FACE VALUE

CERTIFICATION

Appendix 65
I hereby certify that the foregoing is a true statement of all accountable forms received, issued and transferred by me during the period above-stated
AO 5/14/02

and that the beginning and ending balances are correct.

________________________________
Name & Signature of Accountable
Officer