Massachusetts State Auditor Chapter 647 Form
Report on Unaccounted for Variances, Losses, Shortages, Thefts of Funds or Property as Required by Chapter 647, Acts of 1989
Please provide the following information that will serve as your filed report:
From:
Date:
Agency:
Address:
Agency Contact Person/Title/Phone:
Agency Contact E-mail:
Explanation of Condition:
Cause of Condition:
Amount of Funds or Value of Property Involved:
Appropriation Accounts, Trust Funds, Checking Accounts, etc., Involved. List all particulars i.e., account numbers, banks, amounts, description of property:
Agency/Division, Section Involved:
Individual(s) Aware of Incident:
Number of Individuals Having Access to Accounts/Funds Affected:
1 2 3 4+
Law Enforcement Agencies Notified of the Incident:
Other Pertinent Information:
Or send to:
Office of the Massachusetts State Auditor One Ashburton Place Room 1819 Boston MA 02108
