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Use to convey status of military equipment deemed sensitive by chain of command. Send IAW unit SOPs. Reference: FM 19-30.

LINE 1 — DATE AND TIME______________________________(DTG)

LINE 2 — UNIT________________________________________(Unit Making Report)

LINE 3 — STATUS _____________________________________(UP-100 percent Complete or UNIT GREEN to Denote Report With No Discrepancy; if Unit is Green Skip to Line 10; When Discrepancy is Noted Report UNIT RED and Continue Report)

LINE 4 — LOSING UNIT________________________________(Unit Making Report Loss)

LINE 5 — ITEM _______________________________________(Item Lost by Serial Number)

LINE 6 — DTG OF LOSS________________________________(DTG of Loss)

LINE 7 — DETAILS_____________________________________(Circumstances of Loss)

LINE 8 — ACTION TAKEN ______________________________(Actions Taken to Recover the Item)

LINE 9 — NARRATIVE__________________________________(Free Text for Additional Information Required for Clarification of Report)

LINE 10 — AUTHENTICATION___________________________(Report Authentication)