State Agency Schedule of Equipment Purchased for SSA Disability Programs

Instructions for Completion of Form SSA-871

Heading
Insert official name of agency, State, fiscal year, and
reporting period in designated spaces.

Column Entries
Column (a). Description of Eauivment - Enter
description of equipment under appropriate category
(as new EDP equipmentlupgrades or other
equipment) for which disbursements have been made
during the quarter being reported.
Column (b), Tvpe of Av~roval- Enter "C" for items
approved under CO Authority, "R" for items
approved under RO Authority, and "D" for items
purchased under DDS Authority.
Column (c), Date of Approval - Enter date of
funding approval for each item listed under CO and
RO authority. Enter date of purchase for each item
listed under DDS authority.
Column (d - e), Number of Units
SAdditionaVRevlacement)- Enter number of units
purchased in appropriate columns (as additional or
replacement equipment).
Column (0,Unit Cost - Enter the unit cost for each
item listed in column (a)--including taxes, delivery
and installation.

Column ( g ) , Gross Cost - Automatically calculated-derived by multiplying the number of units (listed
under columns d and e) by the unit cost.
Column (h), Trade-in Value, if Replacement Item Enter the expected trade-in value of items being
traded in with purchase of units shown in column (e).
Column (i), Net Cost - Automatically calculated-derived by subtracting the trade-in value (shown in
column h) from the gross cost (shown in column g).

Line Entries
1. New EDP Eauipment/Uvgrades - Enter
description of EDP equipment for which
disbursements have been made during the
quarter being reported.

2. Eauipment - Enter description of other
equipment for which disbursements have been
made during the quarter being reported.
3. Total Net Cost - Automatically calculatedderived by adding the amounts shown in column
(9.
4.

SignaturelDate - Self-explanatory

Paperwork Reduction Act Statements

& 4 1 k 4 & 4 R 4 , /?+ChLLrCd

instructio

gather the ne ssary facts, and

swer the questi

Thefollowing revised PRA Statement will be inserted into theform at its
next scheduled reprinting:
Paperwork Reduction Act Statement - This information collection meets the
requirements of 44 U.S.C. 5 3507, as amended by section 2 of the Paverwork Reduction
Act of 1995. You do not need to answer these questions unless we display a valid Office
of Management and Budget control number. We estimate that it will take about 30
minutes to read the instructions, gather the facts, and answer the questions. You may send
comments on our time estimate above to: SSA, 6401 Security Blvd, Baltimore, MD
21235-6401. Send &comments relating to our time estimate to this address, not the
completedform.