Appendix 75

REPORT OF LOST, STOLEN, DAMAGED OR DESTROYED PROPERTY

Entity Name : BALIBAGO INTEGRATED HIGH SCHOOL Fund Cluster: SEF

Department/Office : BIHS- COMPUTER LAB. 2 RLSDDP No. : ______________
Accountable Officer: ERMA S, JAMON, Ed.D. RLSDDP Date : _____________
Designation : ICT- COORDINATOR PAR No. : IT-2018-06
Police Notified : Yes Police Station : ____________________ PAR Date : June 6, 2018
Date : ___________________________
No

Status of Property : (check applicable box)

Lost Damaged
Stolen Destroyed

Property No. Description Acquisition Cost

IT-2018-06 Laptop Acer Travelmate TMPZ45-G2-MG 30,638.07

Circumstances:

The surviving wife of the late MARK LESTER P. HERNANDEZ, who was the
keeper/holder a Laptop Acer Travelmate issued by the Balibago Integrated High School, Santa
Rosa, Laguna that last November 2018, the said item was misplaced and got lost.

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

ERMA S. JAMON, Ed.D. __________________________________

Signature over Printed Name of the Accountable Officer Signature over Printed Name of the Immediate
Supervisor
November 22, 2018 ________________
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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0

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