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DivineE@ bjbj ,Cm2222{Z(((((UUU-W/W/W/W5dWLXLY$Q[R]b ZUNUUU Z22((<5ZVVVU2((-WVU-WVVVFV(:ǵUVW,KZ0{ZV^U^V2222^V(UUVUUUUU Z Z V FORM FD 2766 (1/93) COMMENTS CDRH CLAIM NO. COMMON ACCOUNTING NUMBER IV COMPLETED BY OFFICE OF COMPLIANCE, CENTER FOR DEVICES AND RADIOLOGICAL HEALTH DATE SIGNATURE PRINTED NAME AND TITLE I affirm that the above employee or representative was on official government business when this claim for damage arose III COMPLETED BY IMMEDIATE SUPERVISOR, EMPLOYEE, OR REPRESENTATIVE DATE SIGNATURE PRINTED NAME, ORGANIZATION, AND ADDRESS I affirm that the ________________________________ listed above, with a (repair/replacement) value of $___________, was (damaged/damaged beyond repair) in my presence during an official test under the provisions of Public Law 90-602. DATE SIGNATURE II COMPLETED BY FOOD AND DRUG INSPECTOR I hereby request $ ________________ for damage to my _______________, make ___________________________, Model No. _________________________, Serial No. _____________________, which was damaged during Food and Drug Administration testing on _________________________________, 19 _____. I COMPLETED BY CLAIMANT (See instructions on Reverse) CLAIM FOR DAMAGE TO AN ELECTRONIC PRODUCT FOOD AND DRUG ADMINISTRATION DEPARTMENT OF HEALTH AND HUMAN SERVICES BC , 0 3 b c ̸̸̸̸̸yo\̸$jChDB*CJ OJQJUphhDCJ OJQJ)hD6B*CJOJQJmHnHphu$jhDB*CJ OJQJUph,hDhDB*CJOJQJmHnHphu&hDB*CJOJQJmHnHphu&hDB*CJ OJQJmHnHphuhDjhDUmHnHujhUmHnHuCWXabqr + , `)~))n)0eF)r))0eb0e0eF)r)V)C , - . $%/0defg b0e0eb0e0eb0eF)r)v0e0eb0e0eb0e0e j0e 0 1 2 3 4 5 _ ` a b c 0eb0eb0e0eb0e) 0eb0e20e`$a$* 00N N!"#$%SummaryInformation( :DocumentSummaryInformation8B_1162798676FPk"XPk"XOle Oh+'0 <HT `lt|ssMike DivineikeikeNormal.dotMichael P. 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