Appendix 58

LIQUIDATION REPORT No. ______________

Date: _____________
Responsibility Center
Agency Code: ____________
Particulars/Description on the nature of cash advance Amount

Total Amount Spent -

Amount of Cash Advance per DV NO. _______________ Dated : ________________
Amount Refunded per O.R. NO. _______________ Dated : _______________
Amount to be Reimbursed
A Certified: Coorectness of the above data B Certified: Purpose of travel/case C Certified: supporting
advance duly accomplished documents complete
and proper

Claimants/Signature Over Printed Name Immediate Supervisor Head Acctng. Section JEV NO.