"Computer Repair Form"

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COMPUTER REPAIR FORM
MUST BE COMPLETED BY A PROFESSIONAL REPAIRMAN
The Personal Property Claims Office must determine whether listed item below was caused by the item being dropped or
mishandled in shipment, or whether the damage was due to fair wear and tear or a manufacturer’s defect.
OWNER’S NAME: _________________________________________ HHG DELIVERY/INCIDENT DATE: __________
ITEM EXAMINED: ________________________________________________ MAKE: __________________________
Model: _______________________________________________________________________________ Year: _______
a. Processor Type and Speed: ___________________
e. Video Card Type: _______________________
b. Hard Drive Capacity: ________________________
f. CD ROM Drive, Type/Speed: ______________
c. RAM Capacity: Internal: ______ External: ______
g. Monitor Size/type: ______________________
d. Sound Card Type: ___________________________
h. Other: ________________________________
1. EXTERNAL DAMAGE. There ____ (was) ____ (was not) external damage to the item.
a. I ___ (was) ___ (was not) able to determine the cause of the external damage. To the best of my knowledge
and belief, damage was caused by: _____________________________________________________________
_________________________________________________________________________________________________________________
b. I came to this conclusion because: _________________________________________________________
Damage Located at : (1) __ Front (2) __ Back (3) __ Right Side (4)__ Left Side (5) __ Top (6) __ Bottom
2. INTERNAL DAMAGE. There ___ (was) ___ (was not) internal damage caused by shipment / power surge:
CIRCLE ONE: (1) Definitely
(2) Probably (3) Cannot Tell
a. I ___ (was) ___ (was not) able to determine the cause of the internal damage. To the best of my knowledge
and belief, damage was caused by: ______________________________________________________________
___________________________ Location of damage: _____________________________________________
b. I came to this conclusion because: _________________________________________________________
3. I estimate the cost of repairing this damage in:
a. Parts:
$
b. Parts:
$
c. Parts:
$
d. Subtotal of replacement parts:
$
e. Cleaning or Other Service Charges:
$
f. Labor:
No. Hours:
@Hourly Rate of:
$
g. Taxes:
Tax Rate of:
$
TOTAL: $_______________
PROFESSIONAL REPAIR FACILITY
Facility Name:
Address:
Telephone Number:
Print Repairman’s Name:
Years of Experience:
Repairman’s Signature:
Date:
COMPUTER REPAIR FORM
MUST BE COMPLETED BY A PROFESSIONAL REPAIRMAN
The Personal Property Claims Office must determine whether listed item below was caused by the item being dropped or
mishandled in shipment, or whether the damage was due to fair wear and tear or a manufacturer’s defect.
OWNER’S NAME: _________________________________________ HHG DELIVERY/INCIDENT DATE: __________
ITEM EXAMINED: ________________________________________________ MAKE: __________________________
Model: _______________________________________________________________________________ Year: _______
a. Processor Type and Speed: ___________________
e. Video Card Type: _______________________
b. Hard Drive Capacity: ________________________
f. CD ROM Drive, Type/Speed: ______________
c. RAM Capacity: Internal: ______ External: ______
g. Monitor Size/type: ______________________
d. Sound Card Type: ___________________________
h. Other: ________________________________
1. EXTERNAL DAMAGE. There ____ (was) ____ (was not) external damage to the item.
a. I ___ (was) ___ (was not) able to determine the cause of the external damage. To the best of my knowledge
and belief, damage was caused by: _____________________________________________________________
_________________________________________________________________________________________________________________
b. I came to this conclusion because: _________________________________________________________
Damage Located at : (1) __ Front (2) __ Back (3) __ Right Side (4)__ Left Side (5) __ Top (6) __ Bottom
2. INTERNAL DAMAGE. There ___ (was) ___ (was not) internal damage caused by shipment / power surge:
CIRCLE ONE: (1) Definitely
(2) Probably (3) Cannot Tell
a. I ___ (was) ___ (was not) able to determine the cause of the internal damage. To the best of my knowledge
and belief, damage was caused by: ______________________________________________________________
___________________________ Location of damage: _____________________________________________
b. I came to this conclusion because: _________________________________________________________
3. I estimate the cost of repairing this damage in:
a. Parts:
$
b. Parts:
$
c. Parts:
$
d. Subtotal of replacement parts:
$
e. Cleaning or Other Service Charges:
$
f. Labor:
No. Hours:
@Hourly Rate of:
$
g. Taxes:
Tax Rate of:
$
TOTAL: $_______________
PROFESSIONAL REPAIR FACILITY
Facility Name:
Address:
Telephone Number:
Print Repairman’s Name:
Years of Experience:
Repairman’s Signature:
Date: