Equipment Assignment Form (Passive)

PRO TECH MONITORING INC EQUIPMENT ASSIGNMENT FORM (PASSIVE) I acknowledge that the following electronic equipment has been assigned to and received by the undersigned: M TD Unit # Bracelet: # Charging Stand # INITIALS 1. This eq uipm ent is the pro perty of P ro Tec h M onitoring Inc . It is expensive equipm ent for which I will have legal and financial responsibility during the term of my temporary custody an d us e. 2. I promise to protect and take care of this property to the best of my ability. Problems with or da ma ge to the equipm ent, will be reported b y m e to the E lectronic M onitoring sta ff imm ediate ly upon detection . 3. By signing this agreement, I promise to reimburse Pro Tech M onitoring Inc. for any loss or damage to the eq uipme nt incurred while in m y possession. The cost of these items are as follows: Miniature Tracking Device (MT D) $1,200.00, the Transmitter, $300.00 and the Charging Stand, $250.00. If I do not return the equipment intact to Pro Tech Mo nitoring Inc. an d/or the m onitoring sta ff upon de ma nd, or upon reachin g the en d of the program participation (whichever comes first), I realize I may be charged with felony theft. Defendant _________ Defendant _________ Defendant _________ Printed Name o f Participant Signature of Participant Date Printed Name of Staff Member Signature of Staff Member Date EQUIPMENT RETURN: All equipment returned as assigned/all equipment undamaged. Prob lems or da mage no ted upo n return as follows: Amount o f damage assessment: W itnessing Staff Member Date 2005 American LegalNet, Inc. www.FormsWorkflow.com