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DOE F 4420.2
All Other Editions Are Obsolete
OMB Burden Disclosure Statement
Public reporting burden for this collection of information is estimated to average 30 minutes per response, including the time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments
regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to Records Management
Division, IM-11 GTN, Paperwork Reduction Project (1910-1000), U.S. Department of Energy, 1000 Independence Avenue, S.W., Washington, DC 20585;
and to the Office of Management and Budget (OMB), Paperwork Reduction Project (1910-1000), Washington, DC 20503.
U.S. Department of Energy
Personal Property Loan Agreement
DOE-PMR 109-1.5103
1. CONTROL NUMBER
2. LOAN DATE 3. EXPIRATION DATE
4. PAGE OF
5. NAME-ADDRESS-TELEPHONE NO./FAX/EMAIL (LENDER) 6. (BORROWER)NAME-ADDRESS-TELEPHONE NO./FAX/EMAIL
7. PURPOSE OF LOAN AND LOCATION WHERE PROPERTY WILL BE USED
8. REFERENCE/CONTRACTUAL DOCUMENTATION/SHIPPING INFORMATION
9. ITEM NO. PROPERTY NO. SERIAL NO. PERSONAL PROPERTY DESCRIPTION ACQUISITION COST
(If additional space is necessary, attach a separate sheet.)
TERMS AND CONDITIONS OF LOAN
1
a. return the loan item(s) in like condition as received from Lender, normal wear and tear excepted, and free of contamination, on or before the
expiration date, unless the loan period is formally extended or the loan is terminated before the due date;
1. The borrower shall:
b. in case of loss or damage of the property loaned, reimburse the Lender at the current price of replacement or repair;
d. agree to indemnify and hold harmless the Lender and the Department of Energy against any and all liability, loss, damages, claims and costs
incidental hereto as a result of Borrower's use or possession of the loaned property; and
Accepted By:
Borrowing Agency/Organization Approval Title Date
Approved By:
Signature of Authorized Lender Title Date
Approved By:
Department of Energy Official Title Date
c. assume all costs involved in preparation, handling, loaning, disconnecting, and transportation from and to the Lender;
e. use the loan property only for the purposes specified in this loan agreement.
4. This is United States Government Property. Title to the property is vested in and will remain with the United States and the property shall be used
only for official purposes. The Lender reserves the right to cancel the loan or to recall the loaned property upon 30 days notice.
3. The Borrower shall account for, or permit inspection of, the loaned property by the Lender after proper notification.
2. The above property shall not be modified, loaned, or transferred to a third party without the written permission of the Lender.
1. Lender's Property Management Office 2. Borrower 3. Custodian (Responsible Property Office) 4. Suspense
(11-01)
QUANTITY
OMB Control No.
1910-1000
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