agency

No.

DISBURSEMENT VOUCHER
Mode of Payment

MDS Check

Date:

Commercial Check

ADA

Others

Payee/Office

Date:

Address

EXPLANATION

A.

Certified

Amount

B.

Approved for Payment

Cash Available
Subject to authority to Debit Account (when applicable)
Supporting documents complete
Signature

Signature

Printed Name

Printed Name

Position

Position
Head, Accounting Unit / Authorized Representative

Date
C.

Agency Head / Authorized Representative

Date

JEV No.

Received Payment

Check/ADA No.

Date

Bank Name

Siganature

Date

Printed Name

Date

Official Receipt/Other |Documents

Accounting Entry:
Responsibility
Center

Accounts and Explanation

Account
Code

Amount
Debit

Credit

TOTAL