Report of Lost Stolen Damaged or Destroyed Semi-Expendable Property (RLSDDSP).xls

	B	C	D	F	H
1
2
3	REPORT OF LOST, STOLEN, DAMAGED OR DESTROYED SEMI-EXPENDABLE PROPERTY
4
5
6	Entity Name : _______________________________				Fund Cluster : _____________
7
8	Department/Office: ______________________				RLSSDDSP No. : ______________
9	Accountable Officer: ____________________________				RLSSDDSP Date : _______________
10	Designation: ____________________________				ICS No:
11	Police Notified:				ICS Date:
12
13			Yes	Police Station:
14			No	Date:
15
16	Status of Semi-expendable Property : (check applicable box)
17			Lost	Damaged
18			Stolen	Destroyed
19
20	Property No:	Description			Acquisition Cost
21	Property No:	Description			Acquisition Cost
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36					Noted by:
37
38					Signature over Printed Name of the Immmediate Supervisor
39	Signature over Printed Name of the Accountable Officer
40
41
42		Date			Date
43
44
45	SUBSCRIBED AND SWORN to before me this _____ day of ____________, affiant exhibiting
46	the above government issued identification card
47
48
49	Doc. No.:
50	Page No. :				Notary Public
51	Book No. :
52	Series of
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100