TB 1-2840-248-20-2
Block 25. Date removed. Enter the julian date the entries in Section II are completed.
Block 26. UIC (This Action). Enter the UIC of the unit completing the form.
Blocks 27 and 28. Leave these blocks blank.
Block 29. Signature and telephone number. The person who completes this form will sign in this block and
enter their telephone number (DSN/AUTOVON or commercial).
Blocks 30, 31, and Remarks. Leave these blocks blank.
NOTE: Take copy 1 and attach it to the old copy 3. If the component/module serial number changes enter the
new serial number in block 4 of copy 2 and line out the old serial number.
COPY 2--SECTION III--REPAIR/OVERHAUL/GAIN DATA (Figure 8, Sheet 3 of 3)
Block 14. Removed from (nomen NHA). Enter "uninstalled" in this block.
Blocks 15 through 24. Leave these blocks blank.
Block 32. Date checked. Enter the julian date that the repair or maintenance action was completed.
Block 33. Signature and telephone number. The person who completes this form, certifying the work
completed, will sign in this block and enter their telephone number (DSN/AUTOVON or commercial).
Block 34. UIC (this action). Enter the unit identification code for the activity that performed the work. If a
contractor enter the CAGE code prefixed with a "K."
Block 35. Manhours to repair/overhaul. Enter the total manhours in hours and tenths it took to do the work.
Block 36. Inspection & action codes. Place the proper letter in the small box ie., "E" for repaired. Do not
use check marks or "X", use the alpha character opposite the maintenance action taken.
Block 37. Reason for gain . After the MWO is applied, enter code "S" in this block.
Block 38. Maint level. Enter the level of the maintenance unit doing the MWO or other directive. ("O" for
AVUM, "F" for AVIM, or "D" for depot.)
Block 39. UIC (shipped to). Enter the Unit Identification Code of the organization to whom the item is
shipped, if unknown leave blank.
Block 40. Actual failure code. Block 10 of this form identifies the apparent failure code or reason for
removal code at removal time for the item listed. Upon further disassembly and repair, the root cause for
failure may be found to be different than that observed at time of removal. The overhaul/repair facility will
enter the actual failure code in this block. See Table 1-2, 1-3,
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