Appendix 39

REPORT OF CASH DISBURSEMENTS

Period Covered _____________________

LGU : ___________________________ Report No. : ______________________

Fund : _________________________ Sheet No. : _______________________

DV/Payroll
Date CAFOA No. Payee Nature of Payment Amount
No.

CERTIFICATION

I hereby certify on my official oath that this Report of Cash Disbursements in _________ sheet(s) is a full, true
and correct statement of all cash disbursements during the period stated above actually made by me in payment
for obligations shown in pertinent disbursement vouchers/payroll.

Name and Signature of the Disbursing

Officer/Cashier

Official Designation
_________
Date