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Appendix A.9
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REPORT OF LOST, STOLEN, DAMAGED OR DESTROYED SEMI-EXPENDABLE PROPERTY
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Entity Name : _________________________Fund Cluster: ______________
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Department/Office : ___________________________________________RLSDDSP No. : ______________
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Accountable Officer : __________________RLSDDSP Date : _
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Designation : ________________________________________________ICS No. : _________________
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Police Notified :YesPolice Station : ____________________ICS Date : ________________
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Date : ___________________________
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 No
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Status of Property : (check applicable box)
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LostDamaged
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StolenDestroyed
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Property No. DescriptionAcquisition Cost
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Circumstances:
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I hereby certify that the item/s and circumstances stated above are true and correct.
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Noted by:
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____________________________________________________________________________
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Signature over Printed Name of the Accountable OfficerSignature over Printed Name of the Immediate Supervisor
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________________________________
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DateDate
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Government Issued ID : __________________
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ID No. : _____________________________
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Date Issued : _________________________
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SUBSCRIBED AND SWORN to before me this ______day of _____________, affiant exhibiting the above government issued identification card.
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Doc. No. _________
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Page No. _________
Notary Public
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Book No. _________
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Series of _________
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