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ANNEX "A"

(Name of Agency)
List of Officials and Employees With Outstanding Cash Advances of P50,000 and Above Aged 30 Days or Over or Over from Due Date of
Liquidation per COA Circular No. 97-002 and Status of Submission of Required Documents per COA Memorandum No. 2004-014
As of December 31, 2003
Status of Submission of Following Documents (Pls. check)
Certified
Statement of Certified Copy of
Date of Purpose of Cash Cash Advance/ Demand Copy of Paid
No. Name/Designation Amount Cash Advance Advance Liquidation Letter Voucher Check Narrative Report Remarks

Submitted by:

CommI
EMD/MPH/claire
Form-Cash Advance 50T
ANNEX "B"
(Name of Agency)
List of Officials and Employees With Outstanding Cash Advances of P50,000 and Above Aged 30 Days or Over or Over from Due Date of
Liquidation per COA Circular No. 97-002 and Status of Submission of Required Documents per COA Memorandum No. 2004-014
For Quarter Ending _______________________
Status of Submission of Following Documents (Pls. check)
Certified
Statement of Certified Copy of
Date of Purpose of Cash Cash Advance/ Demand Copy of Paid
No. Name/Designation Amount Cash Advance Advance Liquidation Letter Voucher Check Narrative Report Remarks

Submitted by:

CommI
EMD/MPH/claire
Form-Cash Advance 50T- Annex B