Appendix 39

__________________________________________________
Entity Name

ADVICE OF CHECKS ISSUED AND CANCELLED

To: The Bank Manager ACIC No. :

___________________ Bank Account No. ______________ Organization Code :
___________________ Fund Cluster :
Date _________________________ Area Code :
NCA No. :

UACS FOR GSB USE ONLY

DATE OF
106

CHECK NO. PAYEE AMOUNT OBJECT

CODE DATE NEGT'D. REMARKS
ISSUE

Total ACIC Amount

Total number of checks: ________ Amount in words __________________________________________________
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 Appendix 39

CANCELLED CHECK Certified Correct By: Received by:

Check No. Date Issued Remarks
Signature over Printed Name of Signature over Printed Name of GSB
Disbursing Officer/Cashier/Head of personnel who received the ACIC
Cash/Treasury Unit

Approved by: Delivered by:

Signature over Printed Name of Head of Signature over Printed Name of Agency
Office/Unit or his/her authorized personnel who delivered the ACIC to the
representative GSB

REPORT SUMMARY
107

Number of ACIC(s) : __________________________________

Grand Total : _________________________________________
Amount in Words : _________________________________________________________________________________

Certified Correct by : Received by:

Signature over Printed Name of Disbursing Signature over Printed Name of GSB personnel who
Officer/Cashier/Head of Cash/Treasury Unit received the ACIC

Approved by: Delivered by:

Signature over Printed Name of Head of Signature over Printed Name of Agency personnel who
Office/Unit or his/her authorized representative delivered the ACIC to the GSB
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