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Statement of <br />Physical Custody of 1033 Program Property <br />* Denotes a required field <br />Law Enforcement Agency Information: <br />*Name: <br />Address: <br />Phone Number: <br />1033 Property issued to: <br />*Name: (LAST) <br />(FIRST) <br />1033 Property: <br />NSN: <br />MAKE: <br />*ITEM NOMENCLATURE: <br />MODEL: <br />*SERIAL NUMBER: <br />ITEM UNIT COST: <br />*QTY OF ITEM: <br />Statement of Physical Custody: <br />I am a Law Enforcement Officer of the aforementioned Law Enforcement Agency. I have <br />physical custody of the item(s) listed above and accept personal responsibility for the property. I <br />further understand that failure on my part to exercise responsibility for the care and protection of <br />the item(s) listed above could result in pecuniary liability. <br />*PRINTED NAME: <br />*SIGNATURE: <br />Figure 3 <br />*DATE: <br />