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:             HOUR          @HOURLY RATE OF:

$

G. TAXES:                    TAX RATE OF:                

$

PROFESSIONAL REPAIR FACILITY 

Facility Name:

Address:

Telephone Number:

Print Repairman’s Name:

Years of Experience

Repairman’s Signature:

Date: