General Form No.

02
Revised January 1992
REIMBURSEMENT EXPENSE RECEIPT
Date No.

Received from ARNEL WENCESLAO Z. HERNANDEZ

(Name)

Vice Mayor-Bambang, Nueva Vizcaya the amount

(Official Designation)

of _____ ONE THOUSAND ONE HUNDRED PESOS ( P 1,100.00 )

(In Words) (In figure)

in payment for Wreath given to the bereaved family - Cabanayan and

(Payment for subsistence, services)

Family of SBC Pres. Iritan.

(rental or transportation should show inclusive dates)

attend Vice Mayors League Island Congress

(Purpose, distance, inclusive points of travel etc.)

PAYEE
Name/Signature
Address
Comm. Tax Cert. No.

Date of Issue
Place of Issue

WITNESS
Name/Signature Richard C. Amoguis
Address Bambang, Nueva Vizcaya
Comm. Tax Cert No. 17345006
Date of Issue 14-Jan-11
Place of Issue Bambang, Nueva Vizcaya