Provincial Government of Camarines Sur Provincial Government of Camarines Sur

FORM B FORM B
Capitol Complex, Cadlan, Pili, Camarines Sur Capitol Complex, Cadlan, Pili, Camarines Sur
CENRR/AR No. CENRR/AR No.

CERTIFICATION OF EXPENSES NOT CERTIFICATION OF EXPENSES NOT

ACKNOWLEDGMENT RECEIPT ACKNOWLEDGMENT RECEIPT
REQUIRING RECEIPTS REQUIRING RECEIPTS
COA Circular No. 2017-001 COA Circular 2004-006 COA Circular No. 2017-001 COA Circular 2004-006

Name of Employee Employee No. Name of Employee Employee No.

Office Office
Division Division
Payee Payee
Particulars Amount Particulars Amount
Name & Signature Name & Signature

Total Total
Purpose Purpose

I hereby certify that the above expenses are incurred as they are necessary for the above cited purpose, that I hereby certify that the above expenses are incurred as they are necessary for the above cited purpose, that
above goods and services were acquired from parties not issuing receipts. And that I am fully aware that willful above goods and services were acquired from parties not issuing receipts. And that I am fully aware that willful
falsification of statements is punishable by law. falsification of statements is punishable by law.
Certified Correct Noted by: Certified Correct Noted by:
Signature Signature

Printed Name Printed Name

Employee Immediate Supervisor Employee Immediate Supervisor
Date Date Date Date