REPORT OF CHECKS ISSUED

_________________________________________________
Agency

Period Covered: ________________

Report No.: ____________
Bank Name/Account No. _________________
Check
DV No. / Responsibility
Date
No.
Center Code
Payroll

Sheet No.: _______________

Payee

Nature of Payment

Amount

123
CERTIFICATION

AO 6/15/02

Disbursing Officer

Date

Appendix 55

I hereby certify that this Report of Checks Issued in _________ sheet(s) is a full, true and correct
statement of all checks released by me in payment for obligations for the period stated and
shown in the attached disbursement vouchers.