A fee will be charge for any key that is lost, stolen, or not returned.  If for any reason, fees are not collectable, they become the responsibility of the authorizing department. (PPM 5-44).  Please print this form and fill it out.

Person Unable to Return Key(s) (Please Print or Type)

Name: _______________________________________________

Employee W number or Student ID: _________________________    Phone Number:_____________________

Department/Division: _____________________________     Position: _________________________________

                    ____  Faculty        ____ Staff        ____ Student        ____ Hourly        ____ Other

Key(s) Being Reported:

Building                                        Room/Location                                            Quantity         Key Number
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________

Fee: WSU Personnel                                                                    Non-WSU Personnel

____ $200.00 Great Grand Master                                               ____ $500.00 Great Grand Master
____ $150.00 Grand Building Master                                          ____ $300.00 Great Building Master
____ $100.00 Department Master                                                ____ $200.00 Department Master
____ $50.00 Department Sub- Master                                         ____ $200.00 Department Sub- Master
____ $50.00 Building Entrance                                                   ____ $100.00 Building Entrance
____ $25.00 Individual Key                                                        ____ $100.00 Individual Key
____ $25.00 Facilities Key                                                          ____ $100.00 Facilities Key

Method of Payment:

____ Paid Cash / Check # ______________                                Received By: ___________________________

(Payroll Deduction)                                                            ____ Deducted from One Paycheck
                                                                                             ____ Deducted from Two Paychecks
                                                                                             ____ Deducted from Three Paychecks
                                                                                             ____ Deducted from Four Paychecks

________________________________________________________________________________________
Signature of Person Paying Fee                                                                            Date

________________________________________________________________________________________
Signature of Dean/ Chair/ etc.                                                                              Date

________________________________________________________________________________________
Signature of Facilities Management Director                                                       Date

________________________________________________________________________________________
Signature of Payroll Director                                                                                Date