ROUTINARY SLIP

Originating Office TARLAC PROVINCIAL JAIL

Date Started/ Forwarded or Processing
Note :

PURCHASE REQUEST

CONTROL IN CONTROL IN
OFFICE SIGNATURE SIGNATURE
No. DATE TIME No. DATE TIME
GSD
BUDGET
ACCOUNTING
PGO

PURCHASE ORDER

CONTROL IN CONTROL IN
OFFICE SIGNATURE SIGNATURE
No. DATE TIME No. DATE TIME
GSD
BUDGET
ACCOUNTING
PGO

VOUCHER

CONTROL IN CONTROL IN
OFFICE SIGNATURE SIGNATURE
No. DATE TIME No. DATE TIME
GSD
BUDGET
ACCOUNTING
TREASURY
PA
PGO

LIST OF SUPPORTING DOCUMENTS

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Prepared by:
 Republic of the Philippines
PROVINCE OF TARLAC
TARLAC PROVINCIAL JAIL
Agency/municipality/ Office

INSPECTION AND ACCEPTANCE REPORT

Supplier SVETLANA'S GENERAL MERCHANDISE AR No.

P O No, DATE INVOICE No. DATE
REQUISITION OffIce/Dept. TARLAC PROVINCIAL JAIL
ITEM No. UNIT QTY DESCRIPTION
bags/
cavans
(50 kls 1,170
RICE (50 Kls/bag) 1,599.00 1,870,830.00
per bag)

SUBTOTAL 1,870,830.00

INSPECTION ACCEPTANCE
DATE INSPECTED: DATE RECEIVEd:

INSPECTED, VERIFIED AND found OK Complete

AS TO QUANTITY And SPECIFICATION
PARTIAL

BERNADETTE MANALILI LITO PANGILINAN

Acting PGSO
INSPECTION OFFICER Procurement officer
INSPECTED AND ACCEPTED
DATE RECEIVED:__________________

COMPLETE
PARTIAL

PCOL SAMUEL V. MUÑOZ (RET)

END USER

I HEREBY CERTIFY THAT I HAVE RECEIVED THE FOLLOWING ITEMS IN GOOD CONDITION AND IN ACCORDANCE WITH
THE SPECIFICATIONS AND REQUIREMENTS THAT I HAVE GIVEN.
Annex 25
DV No.:
DISBURSEMENT VOUCHER
Republic of the Philippines Date:
PROVINCE OF TARLAC

CLASSIFICATION OF DISBURSEMENT
Cash Advance Reimbursement Other Payments
Name of Claimant: SVETLANA'S GENERAL MERCHANDISE ID No./ TIN:
Responsibility
Address: Brgy. Dalayap Tarlac City, Tarlac Center:

Particulars Amount
Payment for prisoners RICE allocation as per supporting papers
hereto attached in the total amount of
Php 1,870,830.00
1,870,830.00
1% witholding Tax - Php 18,708.30 ( 20, 579. 13 )
0.001 Service Charge - Php 1,870.83 1,850,250.87
Php 20,579.13

Amount Due PHP 1,850,250.87

A B C
Certified : Completeness and propriety of supporting Cash Available:
Expenses/Cash Advances necessary , documents/previous cash advance
lawful and incurred under my direct liquidated/existence of funds held in trust:
supervision.

PCOL SAMUEL V MUÑOZ (RET) CRISTINA R. ESPINOSA LORNA M. ARIBE

Provincial Warden Asst. Provincial Accountant Acting-Provincial Treasurer

D E
Received Payment:
Approved For Payment: ____________ Payment:
Check No.: _____________
Bank Name:_____________
Date: _________________
SUSAN A. YAP Signature Over Printed Name/ Position
Governor
JEV No._____________
 Date:________________

DISBURSEMENT VOUCHER (DV) INSTRUCTIONS:

A. The form shall be accomplished as follows:
1. LGU-name of the province/city/municipality
2.DV No./Date- number assigned to the DV by the Accounting Unit and the date of DV preparation.
DV shall be numbered as follows:
00 -00 -00 -0000
Fund Code/ year of issue/ month of issue/ serial no. (one series per year)
3. Classification of Disbursement- put a check "□" mark in the box opposite the classification of
disbursement.
4. Name of Claimnant-name of the payee.
5. ID No./TIN- Identification Number or Tax Identification Number of the claimnant.
6. Address- address of the claimnant.
7. Responsibility Center- code assigned to each cost center.
8. Particulars- brief description of disbursement covered by the DV.
9. Amount- amount of claim covered by the DV.
10. Certified (Box A)-certification of authorized officials that the expense/cash advances
are necessary, lawful and incurred under his direct supervision.
11. Certified (Box B)- certification of the Head of Accounting Unit that the supporting documents
are complete and proper /previous cash advance liquidated/existence of Funds held in trust.
12. Certified (Box C)- certification of the Treasurer as to cash availability.
13. Approved for payment (Box D)-approval of the Head of the Agency or Authorized Official
on the Payment covered by the DV.
14. Received Payment (Box E)-acknowledgement by the claimnant or his duly
representative for the receipt of the check/cash and the date of receipt. The claimnant
/payee shall indicate the no. and the date of check, bank's name and branch and OR no. and
date.
15 JEV No. and Date- assigned JEV No. and Date for reference.

B. This form shall be prepared in triplicate copies to be distributed as follows:

Original- auditor thru the Chief Accountant.
2nd copy- Treasurer
3rd copy- Payee
C. The ALOBS number,code, date shall be stamped on the face of the DV.