State of Wisconsin

Department of Administration

Division of State Agency Services

DOA-6740 (C04/2001)


Please return to:

Risk Management

21 N. Park Street, Suite 5301

Madison, WI  53715

FAX  608-262-9082

Lightning Losses Affidavit






To Risk Management:  ____________________________________________________________________________________

I inspected and/or repaired this damaged item: 



Model Number:


Serial Number:





Date of Purchase:


Purchase Price:




Place Purchased:


Owned by (Dept name):



Campus Address:



Date of Loss:


Time of Loss:






Are damaged item(s) available for inspection? Where?


If not, why?



This damage was solely due to lightning and no other cause whatever because:













Signature of Repair Person



Print Name of Repair Person



Firm Name



Firm Address (Street, City & State)