REPORT OF CHECKS ISSUED

__________________
LGU
________________
Period Covered
Bank Name/Account No. : _____________________ Report No. _________
Sheet No. __________

Check Reponsibility
DV No. Payee Nature of Payment Amount
Date No. Center

CERTIFICATION
Received by:
I certify that this report issued in _______ sheet(s) is a full, true and correct
statement of all checks releaed by me in payment for obligations of the ______
________________________ for the period stated and shown in attached Signature Over Printed Name
disbursement vouchers.

Disbursing Officer Date Date

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