Appendix 46

REIMBURSEMENT EXPENSE RECEIPT

Entity Name: _________________ Fund Cluster : ________________

Date : _______________________ RER No. : ___________________

RECEIVED from ______________________________________

(Name)

_________________________________________________ the amount

(Official Designation)

of __________________________________________ (P__________)
(In Words) (in Figures)

in payment for _______________________________________________

(Payments for subsistence, services,

_________________________________________________________
rental or transportation should show inclusive dates,

_________________________________________________________
purpose, distance, inclusive points of travel, etc.)
PAYEE
Name/Signature __________________________________________
Address ________________________________________________

WITNESS
Name/Signature __________________________________________
Address ________________________________________________

123
 Annex A

BAROBONATIONAL HIGH SCHOOL

(Agency Name)

CERTIFICATION OF EXPENSES NOT REQUIRING RECEIPTS

Pursuant to COA Circular No.2017-001 dated June 19, 2017

Name of Employee JUN MARK A. PETALLAR Empoloyee No./TIN: _________________

Office Barobo National High School

Division Surigao del Sur

Particulars Amount (P)

Van Fare (Barobo-PNU,Agusan del Sur) 58.00

Van Fare (PNU,Agusan del Sur-Barobo) 58.00
Van Fare (Barobo-PNU,Agusan del Sur ) 58.00
Van Fare (PNU,Agusan del Sur- Barobo) 58.00

232.00

Purpose: Attended the Diploma in Teaching Arts major in Dance (DTAD)

I hereby certify that the above expenses areincurred as they are necessary for theabove cited purpose,
that above goods and services were acquired fromparties not issuing receipts. And that I am fully aware
that willful falsification of statements ispunishable by law.
Certified Correct: Noted by:
Signature

Printed Name: JUN MARK A. PETALLAR MARCELA G. MARTICION-ORTEGA

Employee Immediate Supervisor
Date: