PETTY CASH VOUCHER

No.:

PROVINCE OF ANTIQUE

Date

Payee/Office : OFFICE OF THE PROVINCIAL ACCOUNTANT

Address

Responsibility Center Co

New Capitol Building, San Jose, Antique

I. To be filled up upon request

Particulars

41-00-04-01

II. To be filled up upon liquidation

Amount
Total Amount Granted

Keyboard (PS/2)

Total Amount Paid per

Extension Outlet (5 mtrs.)

OR No.
Amount Refunded / (Reimbursed)

Requested by:

Received

Refund

Reimbursement

Paid

DOMINIC A. DEL ROSARIO

Name of Requestor
Approved by:
ESTHER MINNIE A. JULIAN
Immediate Supervisor

Paid by:

MELDY A. LONDRES
Petty Cash Custodian

Liquidation

Submitted:

Reimbursement

Received by:

MELDY A. LONDRES
Petty Cash Custodian
Cash Received by:

DOMINIC A. DEL ROSARIO

Signature over Printed Name of Payee
Date: _______________

Signature of Payee
Date: ________________

No.:
Date
Responsibility Center Code:
41-00-04-01

Received

Refund

Reimbursement

Paid

MELDY A. LONDRES
Petty Cash Custodian
Liquidation

Submitted:

Reimbursement

Received by:

Signature of Payee