LIQUIDATION REPORT Serial No.

_________________
Period Covered ______________________ Date: _____________________

Entity Name: __________________________________________ Responsibility Center Code

Fund Cluster : _________________________________________ ___________________________

PARTICULARS AMOUNT

TOTAL AMOUNT SPENT

AMOUNT OF CASH ADVANCE PER DV NO. _________ DTD: __________
AMOUNT REFUNDED PER OR NO. _____________ DTD: ____________
AMOUNT TO BE REIMBURSED
A Certified: Correctness of the B Certified: Purpose of travel / C Certified: Supporting
above data cash advance duly accomplished documents complete and proper

________________________ ________________________ ________________________

Signature over Printed Name Signature over Printed Name Signature over Printed Name
Claimant Immediate Supervisor Head, Accounting Divison Unit

JEV No. ____________________

Date: ______________________ Date:______________________ Date: ______________________