ANNEX "C"

2622
Republika ng Pilipinas
REPORT OF LOST/INCOMPLETE
Kagawaran ng Pananalapi
CANCELLED/DAMAGED
ACCOUNTABLE FORMS
Kawanihan ng Rentas Internas

Name of Accountable Officer : ___________________________________________________ Date Prepared:

Revenue Region No. : ____________________________________
Revenue District No. : ____________________________________

Form Name Form No./Code/ Inclusive Serial Nos. Quantity Event Reason Time & Date
Denomination Place

Name, Designation & Signature