U.S. DEPARTMENT O F
HOMELAND SECURITY
U. S. COAST GUARD
CG- 3853 (R ev. 6-04)
PERSONAL EFFECTS INVENTORY AND DISPOSITION
SECTION I
VESSEL OR STATION
OWNER, SERIAL NO., GRADE OR RATE
LAST DUTY STATION HOME ADDRESS
NEXT OF KIN ADDRESS (Next of kin)
HOW ACQUIRED
DECEASED ABSENT ON SAILING
MISSING AOL - AWOL
CAPTURED DESERTER
INCAPACITATED
HOUR
DATE
PERSONAL EFFECTS INVENTORY (Itemize by class)
(1) CG special clothing/equipment
(2) Uniform clothing
(3) Money
(4) Negotiable/non-negotiable instruments
(5) Miscellaneous articles of value
ITEM
NO.
CLASS DESCRIPTION OF ARTICLES QUANTITY DISPOSITION (Indicate return to kin or other action)
DATE SIGNATURE (SR. MEMBER INVENTORY BOARD) DATE SIGNATURE (Person taking custody)
DATE SIGNATURE (Member) DATE SIGNATURE AND GRADE (Appointing Officer)
SECTION II - ACTIONS AFFECTING STATUS O F OWNER
CHANGE IN STATUS (If any, describe) DISPOSITION OF MONEY ( Amount, registered mail number, etc.)
NAME AND ADDRESS OF PERSON RECEIVING MONEY
DATE SIGNATURE, GRADE/RATE AND TITLE (Person releasing money)
PREVIOUS EDITIONS MAY BE USED
ORIGINAL - OFFICER DESIG TO ASSUME EFFECTS
Sector Harpswell Sound
ET2 Fred E. SMOOTMAN 1001234, USCG
CGC TAPAWINGO (WPB-1351)
12-987 Elm St., Hawleyville CT 06555
John & Jane Smootman (parents)
12-987 Elm St., Hawleyville CT 06555
x
1307
20 Jun 12
1
Master Lock
1
Cut at 1307, 20 Jun 12, Serial #919309, disposed
2
Sea Bag, olive
1
Return to kin
3
3n1 video game
1
Return to kin
4
Jeep luggage bag
1
Return to kin
5
CAC (ID card)
1
Gov't property: Sent to SPO for destruction
6
Orders fm Basic
1
Return to kin
7
Brown GI glasses
1
Return to kin
8
Prescription
1
RxT123456: Returned to medical for disposal
9
Nasal decongestant
1
OTC med: sent to medical for disposal
10
34R ODU Blouse
5
Return to kin
11
SmLong ODU Trouser
3
Return to kin
12
green Ipod classic
1
120 GB, reviewed for security, return to kin
13
CG rain coat
1
Return to kin
14
Security package
1
Retained by Command
15
ODU undershirts
4
Launder, return to kin
16
Black ODU socks
4 pr
Launder, return to kin
17
SDB jacket
1
Dry clean, return to kin
18
VISA credit card
1
# 1234 2345 3456 4567: return to kin
19
Dell Laptop comput
1
#4b998-72872-61w-272s; HD reviewed; return to kin
20
CG BM3 class book
1 set
Vol. 1 & 2; return to kin
21
Sulfacetamide oint
1
Sent to medical for disposal
22
Apples
6
Perishable--auctioned to crew for $12.00
23
Cash, $12
1
From auction; return to kin
24
Quarters
10
$2.50; Return to kin
end
And no others
20 Jun 12
20 Jun 12
20 Jun 12
20 Jun 12
$14.50 cash
John Smootman, 12-987 Elm St., Hawleyville CT 06555
2 Jul 2012
Page 2 of C G-3853 ( Rev. 6-04)
SECTION III - STATEMENT OF CREDITORS
ATTACH LETT ERS, STATEMENTS OF CREDITORS (Describe each attachment below)
SIGNATURE (Commanding Officer or OIC) DATE
REMARKS
DISTRIBUTION
1. Original and two copies to officer designated by the Commanding Officer to assume custody of the effects.
a. Officer retains original.
b. Copy to be packed with personal effects.
c. Copy to next of kin (if personal effects are shipped to next of kin. Otherwise, copy goes to Supply Center, Baltimore).
2. Copy to Service Record.
3. Copy to Commandant (G-PMP) (if deceased, captured, missing, or incapacitated) or
Copy to Commandant (MPC) (if absent at time of sailing, AWOL, AOL, or deserter).
4. Copy to file of unit preparing inventory.
ORIGINAL - OFFICER DESIG TO ASSUME EFFECTS
1. Bank statement, Bank of America, 15 June 2012, account 987-6666-5543, balance
$1,713.88.
2. Bank statement, Navy Federal Credit Union, 18 June 2012, account 456-4444-3445,
balance $50.00.
3. Car loan, Navy Federal Credit Union, 12 June 2012, loan 008-7700-6543, balance
$12,331.01.
20 Jun 12
Ref: (a) COMDTINST M1770.9, Military Casualties & Decedent Affairs, 29 Sep 2011
(replaced PERSMAN Chapter 11)
Auction of perishable items is normal procedure. See reference (a), 1.K.2.b.
Converting perishables to cash protects their value for transfer to Next-Of-Kin.
Distribution notes: (MAIL HARDCOPY, FAX, OR SCAN & EMAIL (preferred for PSC))
Copy to PDR at SPO
Copy to Decedent Affairs Officer (DAO), usually at Base or TRACEN
Copy to USCG PSC (PSD-mr), Military Records
Copy to USCG PSC (PSD FS-Casualty), Program Manager for Casualty Matters
NOTE ADDRESS: Commander (PSD-mr) or (PSD FS-Casualty), USCG Personnel Service Center,
4200 Wilson Blvd., Suite 1100, STOP 7200, Arlington VA 20598-7200.
In most cases, the Person Authorized to Receive Effects (PERE) is the same as the
Person Authorized to Direct Disposition of remains (PADD). See member's CG-2020D.
If the quantity of effects is very small, they may be hand-delivered to PERE.
Usually there will be more than a seabag-full so in most cases it's best to ship to
PERE using the Household Goods (HHG) Bluebark TONO.
Normal procedure is for clothing to be laundered or dry cleaned, as needed. This is
an authorized Government expense. See reference (a), 1.K.2.d. (Casualty Matters may
reimburse unit. Coordinate reimbursement through DAO.)
Electronic data storage devices in Gov't possession should be reviewed for
potentially embarrassing content and for FOUO or classified content prior to shipment
to PADD. Delete inappropriate or unauthorized files.
Multiple inventories possible, e.g. Locker afloat, barracks room, gym locker, POV.
U.S. DEPARTMENT O F
HOMELAND SECURITY
U. S. COAST GUARD
CG- 3853 (R ev. 6-04)
PERSONAL EFFECTS INVENTORY AND DISPOSITION
SECTION I
VESSEL OR STATION
OWNER, SERIAL NO., GRADE OR RATE
LAST DUTY STATION HOME ADDRESS
NEXT OF KIN ADDRESS (Next of kin)
HOW ACQUIRED
DECEASED ABSENT ON SAILING
MISSING AOL - AWOL
CAPTURED DESERTER
INCAPACITATED
HOUR
DATE
PERSONAL EFFECTS INVENTORY (Itemize by class)
(1) CG special clothing/equipment
(2) Uniform clothing
(3) Money
(4) Negotiable/non-negotiable instruments
(5) Miscellaneous articles of value
ITEM
NO.
CLASS DESCRIPTION OF ARTICLES QUANTITY DISPOSITION (Indicate return to kin or other action)
DATE SIGNATURE (SR. MEMBER INVENTORY BOARD) DATE SIGNATURE (Person taking custody)
DATE SIGNATURE (Member) DATE SIGNATURE AND GRADE (Appointing Officer)
SECTION II - ACTIONS AFFECTING STATUS O F OWNER
CHANGE IN STATUS (If any, describe) DISPOSITION OF MONEY ( Amount, registered mail number, etc.)
NAME AND ADDRESS OF PERSON RECEIVING MONEY
DATE SIGNATURE, GRADE/RATE AND TITLE (Person releasing money)
PREVIOUS EDITIONS MAY BE USED
COPY 1 - OFFICER DESIG TO ASSUME CUST OF EFFECTS
Sector Harpswell Sound
ET2 Fred E. SMOOTMAN 1001234, USCG
CGC TAPAWINGO (WPB-1351)
12-987 Elm St., Hawleyville CT 06555
John & Jane Smootman (parents)
12-987 Elm St., Hawleyville CT 06555
x
1307
31 Apr 06
1
Master Lock
1
Cut at 1307, 31 Apr 06, Serial #919309, disposed
2
U.S. Gov Sea Bag
1
Return to kin
3
3n1 video game
1
Return to kin
4
Jeep luggage bag
1
Return to kin
5
Iron, General Elec
1
Return to kin
6
Orders fm Basic
1
Return to kin
7
Brown GI glasses
1
Return to kin
8
Prescription
1
RxT123456: Returned to medical for disposal
9
Nasal decongestant
1
OTC: sent to medical for disposal
10
34R ODU Blouse
5
Return to kin
11
SmLong ODU Trouser
3
Return to kin
12
MShort ODU Trouser
2
Launder, return to kin
13
CG rain coat
1
Return to kin
14
Security package
1
Retained by Command
15
ODU undershirts
4
Launder, return to kin
16
Black ODU socks
4 pr
Launder, return to kin
17
SDB jacket
1
Dry clean, return to kin
18
VISA credit card
1
# 1234 2345 3456 4567: return to kin
19
Dell Laptop comput
1
#4b998-72872-61w-272s; HD reviewed; return to kin
20
CG BM3 class book
1 set
Vol. 1 & 2; return to kin
21
Sulfacetamide oint
1
Sent to medical for disposal
22
Apples
6
Perishable--auctioned to crew for $12.00
23
Cash, $12
1
From auction; return to kin
24
Quarters
10
$2.50; Return to kin
end
And no others
31 Apr 06
1 May 06
31 Apr 06
1 May 06
$14.50 cash
John Smootman, 12-987 Elm St., Hawleyville CT 06555
3 May 06
Page 2 of C G-3853 ( Rev. 6-04)
SECTION III - STATEMENT OF CREDITORS
ATTACH LETT ERS, STATEMENTS OF CREDITORS (Describe each attachment below)
SIGNATURE (Commanding Officer or OIC) DATE
REMARKS
DISTRIBUTION
1. Original and two copies to officer designated by the Commanding Officer to assume custody of the effects.
a. Officer retains original.
b. Copy to be packed with personal effects.
c. Copy to next of kin (if personal effects are shipped to next of kin. Otherwise, copy goes to Supply Center, Baltimore).
2. Copy to Service Record
3. Copy to Commandant (G-PMP) (if deceased, captured, missing, or incapacitated) or
Copy to Commandant (MPC) (if absent at time of sailing, AWOL, AOL, or deserter).
4. Copy to file of unit preparing inventory.
COPY 1 - OFFICER DESIG TO ASSUME CUST OF EFFECTS
1. Bank statement, Bank of America, 15 April 2006, account 987-6666-5543, balance
$1,713.88.
2. Bank statement, Navy Federal Credit Union, 20 April 2006, account 456-4444-3445,
balance $50.00.
3. Car loan, Navy Federal Credit Union, 12 April 2006, loan 008-7700-6543, balance
$12,331.01.
31 Apr 06
Auction of perishable items is normal procedure. Converting them to cash protects
their value for transfer to Next-Of-Kin.
Distribution notes:
Copy to PDR at SPO
Copy to CGPC (adm-3) Records Room
Copy to Decedent Affairs Officer (DAO), usually at ISC
Copy to Commandant (CG-1222)
In most cases, the Person Authorized to Receive Effects (PERE) is the same as the
Person Authorized to Direct Disposition of remains (PADD).
If the quantity of effects is very small, they may be hand-delivered to PERE.
Usually there will be more than a seabag-full so in most cases it's best to ship to
PERE using the Household Goods (HHG) TONO.
Normal procedure is for clothing to be laundered or dry cleaned, as needed. This is
an authorized Government expense.
Electronic data storage devices should be reviewed for potentially embarrassing
content and for FOUO or classified content prior to shipment to PADD. Delete
inappropriate or unauthorized files.
Multiple inventories may be appropriate. For example: Locker afloat, barracks room
ashore, locker at gym, and POV.
U.S. DEPARTMENT O F
HOMELAND SECURITY
U. S. COAST GUARD
CG- 3853 (R ev. 6-04)
PERSONAL EFFECTS INVENTORY AND DISPOSITION
SECTION I
VESSEL OR STATION
OWNER, SERIAL NO., GRADE OR RATE
LAST DUTY STATION HOME ADDRESS
NEXT OF KIN ADDRESS (Next of kin)
HOW ACQUIRED
DECEASED ABSENT ON SAILING
MISSING AOL - AWOL
CAPTURED DESERTER
INCAPACITATED
HOUR
DATE
PERSONAL EFFECTS INVENTORY (Itemize by class)
(1) CG special clothing/equipment
(2) Uniform clothing
(3) Money
(4) Negotiable/non-negotiable instruments
(5) Miscellaneous articles of value
ITEM
NO.
CLASS DESCRIPTION OF ARTICLES QUANTITY DISPOSITION (Indicate return to kin or other action)
DATE SIGNATURE (SR. MEMBER INVENTORY BOARD) DATE SIGNATURE (Person taking custody)
DATE SIGNATURE (Member) DATE SIGNATURE AND GRADE (Appointing Officer)
SECTION II - ACTIONS AFFECTING STATUS O F OWNER
CHANGE IN STATUS (If any, describe) DISPOSITION OF MONEY ( Amount, registered mail number, etc.)
NAME AND ADDRESS OF PERSON RECEIVING MONEY
DATE SIGNATURE, GRADE/RATE AND TITLE (Person releasing money)
PREVIOUS EDITIONS MAY BE USED
COPY 2 - OFFICER DESIG TO ASSUME CUST OF EFFECTS
Sector Harpswell Sound
ET2 Fred E. SMOOTMAN 1001234, USCG
CGC TAPAWINGO (WPB-1351)
12-987 Elm St., Hawleyville CT 06555
John & Jane Smootman (parents)
12-987 Elm St., Hawleyville CT 06555
x
1307
31 Apr 06
1
Master Lock
1
Cut at 1307, 31 Apr 06, Serial #919309, disposed
2
U.S. Gov Sea Bag
1
Return to kin
3
3n1 video game
1
Return to kin
4
Jeep luggage bag
1
Return to kin
5
Iron, General Elec
1
Return to kin
6
Orders fm Basic
1
Return to kin
7
Brown GI glasses
1
Return to kin
8
Prescription
1
RxT123456: Returned to medical for disposal
9
Nasal decongestant
1
OTC: sent to medical for disposal
10
34R ODU Blouse
5
Return to kin
11
SmLong ODU Trouser
3
Return to kin
12
MShort ODU Trouser
2
Launder, return to kin
13
CG rain coat
1
Return to kin
14
Security package
1
Retained by Command
15
ODU undershirts
4
Launder, return to kin
16
Black ODU socks
4 pr
Launder, return to kin
17
SDB jacket
1
Dry clean, return to kin
18
VISA credit card
1
# 1234 2345 3456 4567: return to kin
19
Dell Laptop comput
1
#4b998-72872-61w-272s; HD reviewed; return to kin
20
CG BM3 class book
1 set
Vol. 1 & 2; return to kin
21
Sulfacetamide oint
1
Sent to medical for disposal
22
Apples
6
Perishable--auctioned to crew for $12.00
23
Cash, $12
1
From auction; return to kin
24
Quarters
10
$2.50; Return to kin
end
And no others
31 Apr 06
1 May 06
31 Apr 06
1 May 06
$14.50 cash
John Smootman, 12-987 Elm St., Hawleyville CT 06555
3 May 06
Page 2 of C G-3853 ( Rev. 6-04)
SECTION III - STATEMENT OF CREDITORS
ATTACH LETT ERS, STATEMENTS OF CREDITORS (Describe each attachment below)
SIGNATURE (Commanding Officer or OIC) DATE
REMARKS
DISTRIBUTION
1. Original and two copies to officer designated by the Commanding Officer to assume custody of the effects.
a. Officer retains original.
b. Copy to be packed with personal effects.
c. Copy to next of kin (if personal effects are shipped to next of kin. Otherwise, copy goes to Supply Center, Baltimore).
2. Copy to Service Record
3. Copy to Commandant (G-PMP) (if deceased, captured, missing, or incapacitated) or
Copy to Commandant (MPC) (if absent at time of sailing, AWOL, AOL, or deserter) .
4. Copy to file of unit preparing inventory.
COPY 2 - OFFICER DESIG TO ASSUME CUST OF EFFECTS
1. Bank statement, Bank of America, 15 April 2006, account 987-6666-5543, balance
$1,713.88.
2. Bank statement, Navy Federal Credit Union, 20 April 2006, account 456-4444-3445,
balance $50.00.
3. Car loan, Navy Federal Credit Union, 12 April 2006, loan 008-7700-6543, balance
$12,331.01.
31 Apr 06
Auction of perishable items is normal procedure. Converting them to cash protects
their value for transfer to Next-Of-Kin.
Distribution notes:
Copy to PDR at SPO
Copy to CGPC (adm-3) Records Room
Copy to Decedent Affairs Officer (DAO), usually at ISC
Copy to Commandant (CG-1222)
In most cases, the Person Authorized to Receive Effects (PERE) is the same as the
Person Authorized to Direct Disposition of remains (PADD).
If the quantity of effects is very small, they may be hand-delivered to PERE.
Usually there will be more than a seabag-full so in most cases it's best to ship to
PERE using the Household Goods (HHG) TONO.
Normal procedure is for clothing to be laundered or dry cleaned, as needed. This is
an authorized Government expense.
Electronic data storage devices should be reviewed for potentially embarrassing
content and for FOUO or classified content prior to shipment to PADD. Delete
inappropriate or unauthorized files.
Multiple inventories may be appropriate. For example: Locker afloat, barracks room
ashore, locker at gym, and POV.
U.S. DEPARTMENT O F
HOMELAND SECURITY
U. S. COAST GUARD
CG- 3853 (R ev. 6-04)
PERSONAL EFFECTS INVENTORY AND DISPOSITION
SECTION I
VESSEL OR STATION
OWNER, SERIAL NO., GRADE OR RATE
LAST DUTY STATION HOME ADDRESS
NEXT OF KIN ADDRESS (Next of kin)
HOW ACQUIRED
DECEASED ABSENT ON SAILING
MISSING AOL - AWOL
CAPTURED DESERTER
INCAPACITATED
HOUR
DATE
PERSONAL EFFECTS INVENTORY (Itemize by class)
(1) CG special clothing/equipment
(2) Uniform clothing
(3) Money
(4) Negotiable/non-negotiable instruments
(5) Miscellaneous articles of value
ITEM
NO.
CLASS DESCRIPTION OF ARTICLES QUANTITY DISPOSITION (Indicate return to kin or other action)
DATE SIGNATURE (SR. MEMBER INVENTORY BOARD) DATE SIGNATURE (Person taking custody)
DATE SIGNATURE (Member) DATE SIGNATURE AND GRADE (Appointing Officer)
SECTION II - ACTIONS AFFECTING STATUS O F OWNER
CHANGE IN STATUS (If any, describe) DISPOSITION OF MONEY ( Amount, registered mail number, etc.)
NAME AND ADDRESS OF PERSON RECEIVING MONEY
DATE SIGNATURE, GRADE/RATE AND TITLE (Person releasing money)
PREVIOUS EDITIONS MAY BE USED
COPY 3 - SERVICE RECORD
Sector Harpswell Sound
ET2 Fred E. SMOOTMAN 1001234, USCG
CGC TAPAWINGO (WPB-1351)
12-987 Elm St., Hawleyville CT 06555
John & Jane Smootman (parents)
12-987 Elm St., Hawleyville CT 06555
x
1307
31 Apr 06
1
Master Lock
1
Cut at 1307, 31 Apr 06, Serial #919309, disposed
2
U.S. Gov Sea Bag
1
Return to kin
3
3n1 video game
1
Return to kin
4
Jeep luggage bag
1
Return to kin
5
Iron, General Elec
1
Return to kin
6
Orders fm Basic
1
Return to kin
7
Brown GI glasses
1
Return to kin
8
Prescription
1
RxT123456: Returned to medical for disposal
9
Nasal decongestant
1
OTC: sent to medical for disposal
10
34R ODU Blouse
5
Return to kin
11
SmLong ODU Trouser
3
Return to kin
12
MShort ODU Trouser
2
Launder, return to kin
13
CG rain coat
1
Return to kin
14
Security package
1
Retained by Command
15
ODU undershirts
4
Launder, return to kin
16
Black ODU socks
4 pr
Launder, return to kin
17
SDB jacket
1
Dry clean, return to kin
18
VISA credit card
1
# 1234 2345 3456 4567: return to kin
19
Dell Laptop comput
1
#4b998-72872-61w-272s; HD reviewed; return to kin
20
CG BM3 class book
1 set
Vol. 1 & 2; return to kin
21
Sulfacetamide oint
1
Sent to medical for disposal
22
Apples
6
Perishable--auctioned to crew for $12.00
23
Cash, $12
1
From auction; return to kin
24
Quarters
10
$2.50; Return to kin
end
And no others
31 Apr 06
1 May 06
31 Apr 06
1 May 06
$14.50 cash
John Smootman, 12-987 Elm St., Hawleyville CT 06555
3 May 06
Page 2 of C G- 3853 ( Rev. 6-04)
SECTION III - STATEMENT OF CREDITORS
ATTACH LETTERS, STATEMENTS OF CREDITORS (Describe each attachment below)
SIGNATURE (Commanding Officer or OIC) DATE
REMARKS
DISTRIBUTION
1. Original and two copies to officer designated by the Commanding Officer to assume custody of the effects.
a. Officer retains original.
b. Copy to be packed with personal effects.
c. Copy to next of kin (if personal effects are shipped to next of kin. Otherwise, copy goes to Supply Center, Baltimore).
2. Copy to Service Record
3. Copy to Commandant (G-PMP) (if deceased, captured, missing, or incapacitated) or
Copy to Commandant (MPC) (if absent at time of sailing, AWOL, AOL, or deserter).
4. Copy to file of unit preparing inventory.
COPY 3 - SERVICE RECORD
1. Bank statement, Bank of America, 15 April 2006, account 987-6666-5543, balance
$1,713.88.
2. Bank statement, Navy Federal Credit Union, 20 April 2006, account 456-4444-3445,
balance $50.00.
3. Car loan, Navy Federal Credit Union, 12 April 2006, loan 008-7700-6543, balance
$12,331.01.
31 Apr 06
Auction of perishable items is normal procedure. Converting them to cash protects
their value for transfer to Next-Of-Kin.
Distribution notes:
Copy to PDR at SPO
Copy to CGPC (adm-3) Records Room
Copy to Decedent Affairs Officer (DAO), usually at ISC
Copy to Commandant (CG-1222)
In most cases, the Person Authorized to Receive Effects (PERE) is the same as the
Person Authorized to Direct Disposition of remains (PADD).
If the quantity of effects is very small, they may be hand-delivered to PERE.
Usually there will be more than a seabag-full so in most cases it's best to ship to
PERE using the Household Goods (HHG) TONO.
Normal procedure is for clothing to be laundered or dry cleaned, as needed. This is
an authorized Government expense.
Electronic data storage devices should be reviewed for potentially embarrassing
content and for FOUO or classified content prior to shipment to PADD. Delete
inappropriate or unauthorized files.
Multiple inventories may be appropriate. For example: Locker afloat, barracks room
ashore, locker at gym, and POV.
U.S. DEPARTMENT O F
HOMELAND SECURITY
U. S. COAST GUARD
CG- 3853 (R ev. 6-04)
PERSONAL EFFECTS INVENTORY AND DISPOSITION
SECTION I
VESSEL OR STATION
OWNER, SERIAL NO., GRADE OR RATE
LAST DUTY STATION HOME ADDRESS
NEXT OF KIN ADDRESS (Next of kin)
HOW ACQUIRED
DECEASED ABSENT ON SAILING
MISSING AOL - AWOL
CAPTURED DESERTER
INCAPACITATED
HOUR
DATE
PERSONAL EFFECTS INVENTORY (Itemize by class)
(1) CG special clothing/equipment
(2) Uniform clothing
(3) Money
(4) Negotiable/non-negotiable instruments
(5) Miscellaneous articles of value
ITEM
NO.
CLASS DESCRIPTION OF ARTICLES QUANTITY DISPOSITION (Indicate return to kin or other action)
DATE SIGNATURE (SR. MEMBER INVENTORY BOARD) DATE SIGNATURE (Person taking custody)
DATE SIGNATURE (Member) DATE SIGNATURE AND GRADE (Appointing Officer)
SECTION II - ACTIONS AFFECTING STATUS O F OWNER
CHANGE IN STATUS (If any, describe) DISPOSITION OF MONEY ( Amount, registered mail number, etc.)
NAME AND ADDRESS OF PERSON RECEIVING MONEY
DATE SIGNATURE, GRADE/RATE AND TITLE (Person releasing money)
PREVIOUS EDITIONS MAY BE USED
COPY 4 - COMDT (G-PMP) IF DEC, CAP, MIS, INCAP
Sector Harpswell Sound
ET2 Fred E. SMOOTMAN 1001234, USCG
CGC TAPAWINGO (WPB-1351)
12-987 Elm St., Hawleyville CT 06555
John & Jane Smootman (parents)
12-987 Elm St., Hawleyville CT 06555
x
1307
31 Apr 06
1
Master Lock
1
Cut at 1307, 31 Apr 06, Serial #919309, disposed
2
U.S. Gov Sea Bag
1
Return to kin
3
3n1 video game
1
Return to kin
4
Jeep luggage bag
1
Return to kin
5
Iron, General Elec
1
Return to kin
6
Orders fm Basic
1
Return to kin
7
Brown GI glasses
1
Return to kin
8
Prescription
1
RxT123456: Returned to medical for disposal
9
Nasal decongestant
1
OTC: sent to medical for disposal
10
34R ODU Blouse
5
Return to kin
11
SmLong ODU Trouser
3
Return to kin
12
MShort ODU Trouser
2
Launder, return to kin
13
CG rain coat
1
Return to kin
14
Security package
1
Retained by Command
15
ODU undershirts
4
Launder, return to kin
16
Black ODU socks
4 pr
Launder, return to kin
17
SDB jacket
1
Dry clean, return to kin
18
VISA credit card
1
# 1234 2345 3456 4567: return to kin
19
Dell Laptop comput
1
#4b998-72872-61w-272s; HD reviewed; return to kin
20
CG BM3 class book
1 set
Vol. 1 & 2; return to kin
21
Sulfacetamide oint
1
Sent to medical for disposal
22
Apples
6
Perishable--auctioned to crew for $12.00
23
Cash, $12
1
From auction; return to kin
24
Quarters
10
$2.50; Return to kin
end
And no others
31 Apr 06
1 May 06
31 Apr 06
1 May 06
$14.50 cash
John Smootman, 12-987 Elm St., Hawleyville CT 06555
3 May 06
Page 2 of C G- 3853 ( Rev. 6-04)
SECTION III - STATEMENT OF CREDITORS
ATTACH LETTERS, STATEMENTS OF CREDITORS (Describe each attachment below)
SIGNATURE (Commanding Officer or OIC) DATE
REMARKS
DISTRIBUTION
1. Original and two copies to officer designated by the Commanding Officer to assume custody of the effects.
a. Officer retains original.
b. Copy to be packed with personal effects.
c. Copy to next of kin (if personal effects are shipped to next of kin. Otherwise, copy goes to Supply Center, Baltimore).
2. Copy to Service Record
3. Copy to Commandant (G-PMP) (if deceased, captured, missing, or incapacitated) or
Copy to Commandant (MPC) (if absent at time of sailing, AWOL, AOL, or deserter).
4. Copy to file of unit preparing inventory.
COPY 4 - COMDT (PS) IF DEC, CAP, MIS, INCAP
1. Bank statement, Bank of America, 15 April 2006, account 987-6666-5543, balance
$1,713.88.
2. Bank statement, Navy Federal Credit Union, 20 April 2006, account 456-4444-3445,
balance $50.00.
3. Car loan, Navy Federal Credit Union, 12 April 2006, loan 008-7700-6543, balance
$12,331.01.
31 Apr 06
Auction of perishable items is normal procedure. Converting them to cash protects
their value for transfer to Next-Of-Kin.
Distribution notes:
Copy to PDR at SPO
Copy to CGPC (adm-3) Records Room
Copy to Decedent Affairs Officer (DAO), usually at ISC
Copy to Commandant (CG-1222)
In most cases, the Person Authorized to Receive Effects (PERE) is the same as the
Person Authorized to Direct Disposition of remains (PADD).
If the quantity of effects is very small, they may be hand-delivered to PERE.
Usually there will be more than a seabag-full so in most cases it's best to ship to
PERE using the Household Goods (HHG) TONO.
Normal procedure is for clothing to be laundered or dry cleaned, as needed. This is
an authorized Government expense.
Electronic data storage devices should be reviewed for potentially embarrassing
content and for FOUO or classified content prior to shipment to PADD. Delete
inappropriate or unauthorized files.
Multiple inventories may be appropriate. For example: Locker afloat, barracks room
ashore, locker at gym, and POV.
U.S. DEPARTMENT O F
HOMELAND SECURITY
U. S. COAST GUARD
CG- 3853 (R ev. 6-04)
PERSONAL EFFECTS INVENTORY AND DISPOSITION
SECTION I
VESSEL OR STATION
OWNER, SERIAL NO., GRADE OR RATE
LAST DUTY STATION HOME ADDRESS
NEXT OF KIN ADDRESS (Next of kin)
HOW ACQUIRED
DECEASED ABSENT ON SAILING
MISSING AOL - AWOL
CAPTURED DESERTER
INCAPACITATED
HOUR
DATE
PERSONAL EFFECTS INVENTORY (Itemize by class)
(1) CG special clothing/equipment
(2) Uniform clothing
(3) Money
(4) Negotiable/non-negotiable instruments
(5) Miscellaneous articles of value
ITEM
NO.
CLASS DESCRIPTION OF ARTICLES QUANTITY DISPOSITION (Indicate return to kin or other action)
DATE SIGNATURE (SR. MEMBER INVENTORY BOARD) DATE SIGNATURE (Person taking custody)
DATE SIGNATURE (Member) DATE SIGNATURE AND GRADE (Appointing Officer)
SECTION II - ACTIONS AFFECTING STATUS O F OWNER
CHANGE IN STATUS (If any, describe) DISPOSITION OF MONEY ( Amount, registered mail number, etc.)
NAME AND ADDRESS OF PERSON RECEIVING MONEY
DATE SIGNATURE, GRADE/RATE AND TITLE (Person releasing money)
PREVIOUS EDITIONS MAY BE USED
COPY 5 - COMDT (MPC) AWOL, AOL, DESERTER
Sector Harpswell Sound
ET2 Fred E. SMOOTMAN 1001234, USCG
CGC TAPAWINGO (WPB-1351)
12-987 Elm St., Hawleyville CT 06555
John & Jane Smootman (parents)
12-987 Elm St., Hawleyville CT 06555
x
1307
31 Apr 06
1
Master Lock
1
Cut at 1307, 31 Apr 06, Serial #919309, disposed
2
U.S. Gov Sea Bag
1
Return to kin
3
3n1 video game
1
Return to kin
4
Jeep luggage bag
1
Return to kin
5
Iron, General Elec
1
Return to kin
6
Orders fm Basic
1
Return to kin
7
Brown GI glasses
1
Return to kin
8
Prescription
1
RxT123456: Returned to medical for disposal
9
Nasal decongestant
1
OTC: sent to medical for disposal
10
34R ODU Blouse
5
Return to kin
11
SmLong ODU Trouser
3
Return to kin
12
MShort ODU Trouser
2
Launder, return to kin
13
CG rain coat
1
Return to kin
14
Security package
1
Retained by Command
15
ODU undershirts
4
Launder, return to kin
16
Black ODU socks
4 pr
Launder, return to kin
17
SDB jacket
1
Dry clean, return to kin
18
VISA credit card
1
# 1234 2345 3456 4567: return to kin
19
Dell Laptop comput
1
#4b998-72872-61w-272s; HD reviewed; return to kin
20
CG BM3 class book
1 set
Vol. 1 & 2; return to kin
21
Sulfacetamide oint
1
Sent to medical for disposal
22
Apples
6
Perishable--auctioned to crew for $12.00
23
Cash, $12
1
From auction; return to kin
24
Quarters
10
$2.50; Return to kin
end
And no others
31 Apr 06
1 May 06
31 Apr 06
1 May 06
$14.50 cash
John Smootman, 12-987 Elm St., Hawleyville CT 06555
3 May 06
Page 2 of C G- 3853 ( Rev. 6-04)
SECTION III - STATEMENT OF CREDITORS
ATTACH LETTERS, STATEMENTS OF CREDITORS (Describe each attachment below)
SIGNATURE (Commanding Officer or OIC) DATE
REMARKS
DISTRIBUTION
1. Original and two copies to officer designated by the Commanding Officer to assume custody of the effects.
a. Officer retains original.
b. Copy to be packed with personal effects.
c. Copy to next of kin (if personal effects are shipped to next of kin. Otherwise, copy goes to Supply Center, Baltimore).
2. Copy to Service Record
3. Copy to Commandant (G-PMP) (if deceased, captured, missing, or incapacitated) or
Copy to Commandant (MPC) (if absent at time of sailing, AWOL, AOL, or deserter).
4. Copy to file of unit preparing inventory.
COPY 5 - COMDT (PE) AWOL, AOL, DESERTER
1. Bank statement, Bank of America, 15 April 2006, account 987-6666-5543, balance
$1,713.88.
2. Bank statement, Navy Federal Credit Union, 20 April 2006, account 456-4444-3445,
balance $50.00.
3. Car loan, Navy Federal Credit Union, 12 April 2006, loan 008-7700-6543, balance
$12,331.01.
31 Apr 06
Auction of perishable items is normal procedure. Converting them to cash protects
their value for transfer to Next-Of-Kin.
Distribution notes:
Copy to PDR at SPO
Copy to CGPC (adm-3) Records Room
Copy to Decedent Affairs Officer (DAO), usually at ISC
Copy to Commandant (CG-1222)
In most cases, the Person Authorized to Receive Effects (PERE) is the same as the
Person Authorized to Direct Disposition of remains (PADD).
If the quantity of effects is very small, they may be hand-delivered to PERE.
Usually there will be more than a seabag-full so in most cases it's best to ship to
PERE using the Household Goods (HHG) TONO.
Normal procedure is for clothing to be laundered or dry cleaned, as needed. This is
an authorized Government expense.
Electronic data storage devices should be reviewed for potentially embarrassing
content and for FOUO or classified content prior to shipment to PADD. Delete
inappropriate or unauthorized files.
Multiple inventories may be appropriate. For example: Locker afloat, barracks room
ashore, locker at gym, and POV.