Appendix 29

FUND UTILIZATION REQUEST AND STATUS FURS No. : ______________

_____________________________________ Date : __________________
LGU Fund :__________________

Payee

Office

Address

Project/Purpose Particulars Account Code Amount

Total
A. Certified: Charges to special trust account necessary, B. Certified: Funds available and utilized for
lawful and under my direct supervision; and supporting the purpose/adjustment necessary as
documents valid, proper and legal indicated above

Signature : __________________________________ Signature : ____________________________

Printed Name: __________________________________ Printed Name: ____________________________

Position : __________________________________ Position : ____________________________

Head, Requesting Office/Authorized Head, Accounting Division/Unit/
Representative Authorized Representative
Date : _______________________________ Date : ____________________________

C. STATUS OF UTILIZATION
Reference Amount
Balance
FURS/JEV/RCI/ Utilization Payable Payment Due and
Date Particulars Not Yet Due Demandable
RADAI No.
(a) (b) (c) (a-b) (b-c)