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Staff Manual Guide 2620.4, Attachment A

FDA LOAN AGREEMENT NUMBER (Location-fiscal year-sequential number)

This agreement is entered into by (complete name and address of borrower) and the Food and Drug Administration (hereinafter referred to as FDA), (address of lending activity), with reference to the loan by FDA to (name of borrower) of the following Government-owned property:

(Complete description of property to be loaned, as shown on inventory listing, to include serial number and FDA number.)

The following points represent our understanding regarding the above listed property:

1. The property belongs to FDA, is loaned under the criteria set forth in paragraph 2., B., SMG FDA 2620.4, (and a stipulation as to whether or not there is any reimbursement).

2. (A statement as to the intended use of the property, and the benefits to be derived by the Government.)

3. The property may not be transferred by (borrower) to a third party.

4. (Borrower) will give FDA not less than (amount of time) advance notice of their intent to return this property to FDA.

5. It is understood that FDA reserves the right to terminate this loan agreement at any time.

6. (Borrower) is responsible for delivery and/or return of the property at own expense in as good a condition as when loaned, fair wear and tear excepted.

7. (Borrower) stipulates that he is in compliance with Title VI of the Civil Rights Act of 1964 by virtue of participation in (list the DHHS program), or (Borrower) has executed Form HHS-690 (copy attached).

8. (Borrower) assumes full responsibility and liability for any claims that may arise as a result of operation of this equipment for the period it is in the possession of (borrower).

(Borrower's Signature) __________________________________________ Date______

(Signature of FDA Official Authorized to Make Loan) __________________Date______