| Social Security Administration |
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Form Approved OMB No. 0960-0421 |
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| STATE AGENCY SCHEDULE OF EQUIPMENT PURCHASED FOR SSA DISABILITY PROGRAMS |
| (See instructions for completing form on reverse) |
| Name or Agency: |
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State |
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Fiscal Year |
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Reporting Period |
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Number of units |
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Trade-in |
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Type |
Date |
_______________________________ |
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Unit |
Gross |
Value, If |
Net |
| Description of Equipment |
of |
of |
Addi- |
Replace- |
Cost |
Cost |
Replace- |
Cost |
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Approval |
Approval |
tional |
ment |
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ment Item |
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| (a) |
(b) |
(c) |
(d) |
(e) |
(f) |
(g) |
(h) |
(i) |
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| 1. New EDP Equipment/Upgrades |
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$0.00 |
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$0.00 |
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$0.00 |
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$0.00 |
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$0.00 |
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$0.00 |
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$0.00 |
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$0.00 |
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$0.00 |
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$0.00 |
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$0.00 |
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$0.00 |
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$0.00 |
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$0.00 |
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$0.00 |
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$0.00 |
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$0.00 |
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$0.00 |
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$0.00 |
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$0.00 |
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$0.00 |
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$0.00 |
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$0.00 |
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$0.00 |
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$0.00 |
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$0.00 |
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$0.00 |
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$0.00 |
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$0.00 |
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| 2. Equipment |
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$0.00 |
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$0.00 |
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$0.00 |
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$0.00 |
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$0.00 |
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$0.00 |
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$0.00 |
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$0.00 |
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$0.00 |
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$0.00 |
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$0.00 |
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$0.00 |
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$0.00 |
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$0.00 |
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$0.00 |
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$0.00 |
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$0.00 |
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$0.00 |
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$0.00 |
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$0.00 |
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$0.00 |
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| Total net cost of above equipment ................................................................................................... |
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$ |
$0.00 |
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| I certify that the equipment listed above is necessary for the administration of the SSA Disability Program. |
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| Signature |
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Date |
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| Form SSA-871 (6-2001) |
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| Destroy All Prior Editions |
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