Appendix 75

REPORT OF LOST, STOLEN, DAMAGED OR DESTROYED PROPERTY

Entity Name : KALABUSO ELEMENTARY SCHOOL 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

N/A N/A N/A

Circumstances:

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

ERICSON F. GARCIA FERNANDO T. ESPINOSA JR

Signature over Printed Name of the Accountable Officer Signature over Printed Name of the Immediate
Supervisor
August 16, 2021 16-Aug-21
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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