Appendix 75

REPORT OF LOST, STOLEN, DAMAGED OR DESTROYED PROPERTY

Entity Name : __________________________ Fund Cluster: ______________

Department/Office : ___________________________________________ RLSDDP No. : ______________
Accountable Officer : _________________________________________ RLSDDP Date : _____________
Designation : ________________________________________________ PAR No. : _________________
Police Notified : Yes Police Station : ____________________ PAR Date : ________________
Date : ___________________________
No

Status of Property : (check applicable box)

Lost Damaged
Stolen Destroyed

Property No. Description Acquisition Cost

Circumstances:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

I hereby certify that the item/s and circumstances stated above are
true and correct. Noted by:

__________________________________________ __________________________________
Signature over Printed Name of the Accountable Officer Signature over Printed Name of the
Immediate Supervisor
________________ ________________
Date Date

Government Issued ID : __________________

ID No. : _____________________________
Date Issued : _________________________

SUBSCRIBED AND SWORN to before me this ______day of _____________, affiant exhibiting the above
government issued identification card.

Doc. No. _________

Page No. _________ Notary Public
Book No. _________
Series of _________

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