Appendix E "Donation Tracking - Terms of Acceptance" - Missouri

What Is Appendix E?

This is a legal form that was released by the Missouri Department of Mental Health - a government authority operating within Missouri. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on June 1, 2010;
  • The latest edition provided by the Missouri Department of Mental Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Appendix E by clicking the link below or browse more documents and templates provided by the Missouri Department of Mental Health.

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Download Appendix E "Donation Tracking - Terms of Acceptance" - Missouri

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Appendix E
(To be put on RO letterhead)
Terms of Acceptance
I, _____________________________________, agree to accept the below described donated
equipment and have examined the equipment and agree to accept it in “as is condition”. I
understand that by accepting the equipment described below I agree to accept the responsibility
for all up keep, repairs and liability to said equipment, including any physical adjustments that
need to be made for personal use. I also understand that once I accept the described equipment
the Department of Mental Health, Division of Developmental Disabilities _______ Regional
Office and their agents are free and released from any liability pertaining to this equipment.
I hereby, for myself, my heirs, executors and administrators, waive and release any and all rights
and claims for damages I may have against the Department of Mental Health, Division of
Development Disabilities, ________ Regional Office, or any other person connected to this
program, their agents, representatives and assigns for any and all injuries to or illness suffered by
myself or any other person(s) resulting from the used of said equipment.
Description of equipment being accepted: _____________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Your signature on this document verifies you have read and agree to the terms above.
______________________________________
_________________________
Recipient’s signature
Date
______________________________________
__________________________
Regional Office Representative
Date
Individual’s / Consumer’s name
cc:
RO
Individual/Family
Consumer File
1.030 Donation Tracking Policy
06.01.10
Appendix E
(To be put on RO letterhead)
Terms of Acceptance
I, _____________________________________, agree to accept the below described donated
equipment and have examined the equipment and agree to accept it in “as is condition”. I
understand that by accepting the equipment described below I agree to accept the responsibility
for all up keep, repairs and liability to said equipment, including any physical adjustments that
need to be made for personal use. I also understand that once I accept the described equipment
the Department of Mental Health, Division of Developmental Disabilities _______ Regional
Office and their agents are free and released from any liability pertaining to this equipment.
I hereby, for myself, my heirs, executors and administrators, waive and release any and all rights
and claims for damages I may have against the Department of Mental Health, Division of
Development Disabilities, ________ Regional Office, or any other person connected to this
program, their agents, representatives and assigns for any and all injuries to or illness suffered by
myself or any other person(s) resulting from the used of said equipment.
Description of equipment being accepted: _____________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Your signature on this document verifies you have read and agree to the terms above.
______________________________________
_________________________
Recipient’s signature
Date
______________________________________
__________________________
Regional Office Representative
Date
Individual’s / Consumer’s name
cc:
RO
Individual/Family
Consumer File
1.030 Donation Tracking Policy
06.01.10