OBLIGATION REQUEST AND STATUS Serial No.
:
Republic of the Philippines Date :
DEPARTMENT OF THE INTERIOR AND LOCAL GOVERNMENT Fund Cluster :
Regional Office No. 2
Regional Government Center, Carig Sur, Tuguegarao City, Cagayan
Payee 0
Office DILG Cagayan
Address Carig, Tuguegarao City
Responsibility UACS Object
Particulars MFO/PAP Amount
Center Code
Payment of wages the period of
_________________________ as per supporting
papers hereto attached in the amount of.....
Account Number: SA
Total
A. B.
Certified: Charges to appropriation/alloment are Certified: Allotment available and obligated
necessary, lawful and under my direct supervision;and for the purpose/adjustment necessary as
supporting documents valid, proper and legal indicated above
Signature :
Signature : ______________________________
Printed Name : Printed Name: JAYSON P. VERZON
Position :
Position : Budget Officer
Head, Requesting Office/Authorized Representative Head, Budget Division/Unit/Authorized
Representative
Date : ___________________________________ Date : ____________________________
C. STATUS OF OBLIGATION
Reference Amount
Balance
ORS/JEV/Check/ Obligation Payable Payment Due and
Date Particulars Not Yet Due
ADA/TRA No. Demandable
(a) (b) (c) (a-b) (b-c)
Appendix 32
DEPARTMENT OF THE INTERIOR AND LOCAL GOVERNMENT Fund Cluster
Date:
DISBURSEMENT VOUCHER DV No. :
Mode of
MDS Check Commercial Check ADA Others (Please specify)
Payment
TIN/Employee No. OR/BURS no.
Payee
Address
Particulars Responsibility MFO/PAP Amount
Center
Payment of wages the period of _________________________ as per
supporting papers hereto attached in the amount of.....
Account Number: SA
Amount Due
A Certified: Expenses/Cash Advance necessary, lawful and incurred under my direct supervision
C/MLGOO
B Accounting Entry:
Account Title UACS Code Debit Credit
C Certified : D Approved for Payment
Cash Available
Subject to authority to Debit Account (when applicable)
Supporting documents complete and amount claimed proper
Signature Signature
Printed Printed
Name MA. CRISTINA T. RUSTIA Name RUPERTO B. MARIBBAY, JR., CESO V
Adminjstrative Assistant II Provincial Director
Position Position
Head, Accounting Unit/Authorized Representative Agency Head/Authorized Representative
Date Date
E Receipt of Payment JEV No.
Check/ Date: Bank Name & Account Number
ADA No. :
Signature : Date: Printed Name: Date
Official Receipt No. & Date/Other Documents
Appendix 32
DEPARTMENT OF THE INTERIOR AND LOCAL GOVERNMENT Fund Cluster
Entity Name
Date:
DISBURSEMENT VOUCHER DV No. :
Mode of
MDS Check Commercial Check ADA Others (Please specify)
Payment
Payee TIN/Employee No. OR/BURS no.
Address
Particulars Responsibility MFO/PAP Amount
Center
Reimbursement of trasportation expenses for the period of
______________________ as per supporting papers hereto attached in
the amount of…
Account Number:
Amount Due
A Certified: Expenses/Cash Advance necessary, lawful and incurred under my direct supervision
C/MLGOO
B Accounting Entry:
Account Title UACS Code Debit Credit
C Certified : D Approved for Payment
Cash Available
Subject to authority to Debit Account (when applicable)
Supporting documents complete and amount claimed proper
Signature Signature
Printed Printed
Name CRISTINA T. RUSTIA Name RUPERTO B. MARIBBAY, JR., CESO V
Administrative Assistant II Provincial Director
Position Position
Accounting Unit/Authorized Representative Agency Head/Authorized Representative
Date Date
E Receipt of Payment JEV No.
Check/ Date: Bank Name & Account Number
ADA No. :
Signature : Date: Printed Name: Date
Official Receipt No. & Date/Other Documents
Appendix 32
DEPARTMENT OF THE INTERIOR AND LOCAL GOVERNMENT Fund Cluster
Entity Name
Date:
DISBURSEMENT VOUCHER DV No. :
Mode of
MDS Check Commercial Check ADA Others (Please specify)
Payment
Payee TIN/Employee No. OR/BURS no.
Address
Particulars Responsibility MFO/PAP Amount
Center
Reimbursement of communication expenses for the period of
___________________________ as per supporting papers hereto
attached in the amount of…
Account Number:
Amount Due
A Certified: Expenses/Cash Advance necessary, lawful and incurred under my direct supervision
C/MLGOO
B Accounting Entry:
Account Title UACS Code Debit Credit
C Certified : D Approved for Payment
Cash Available
Subject to authority to Debit Account (when applicable)
Supporting documents complete and amount claimed proper
Signature Signature
Printed Printed
Name CRISTINA T. RUSTIA Name RUPERTO B. MARIBBAY, JR., CESO V
Administrative Assistant II Provincial Director
Position Position
Accounting Unit/Authorized Representative Agency Head/Authorized Representative
Date Date
E Receipt of Payment JEV No.
Check/ Date: Bank Name & Account Number
ADA No. :
Signature : Date: Printed Name: Date
Official Receipt No. & Date/Other Documents
Republic of the Philippines
DEPARTMENT OF THE INTERIOR AND LOCAL GOVERNMENT
Regional Office 02
RGC, Carig Sur, Tuguegarao City
CERTIFICATE OF TRAVEL COMPLETED
Date:
RUPERTO B. MARIBBAY, JR., CESO V
Authorized Signatory
Provincial Director
Designation
I CERTIFY that I have completed the travel authorized in the (pls. See attached) under the conditions
indicated below:
x Strictly in accordance with approved itinerary.
Cut short as explained below. Excess payment in the amount of _______________ refunded
O.R. dated .
Extended as explained below.
EXPLANATION AND/OR JUSTIFICATION:
Evidence of Travel hereto attached:
1. Travel Order
2. Certificate of Appearance
3. Itinerary of Travel
4. Disbursement Voucher
5. Certificate of travel Completed
Respectfully Submitted:
Contact Tracer
On evidence and information of which I have knowledge the travel was actually undertaken.
C/MLGOO
unded
Republic of the Philippines
DEPARTMENT OF THE INTERIOR AND LOCAL GOVERNMENT
Regional Office 02
RGC, Carig Sur, Tuguegarao City
ITINERARY OF TRAVEL
NAME:
OFFICIAL STATION:
PURPOSE OF TRAVEL:
TIME MEANS OF TRANSPOR TRAVEL
DATE PLACE TO BE VISITED DEPARTURE ARRIVAL TRANSPOR- TATION ALLOWANCE
TATION
T O T A L:
I certify that I (a) have received the foregoing itinerary;
(b) that the travel is necessary to the service;
(c) the period covered is reasonable and
(d) the expenses claimed are proper.
PREPARED BY: RECOMMENDED BY:
Name (Contact Tracer) C/MLGOO
APPROVED BY:
RUPERTO B. MARIBBAY, JR., CESO V
Provincial Director
blic of the Philippines
INTERIOR AND LOCAL GOVERNMENT
egional Office 02
ig Sur, Tuguegarao City
RARY OF TRAVEL
TOTAL
C/MLGOO
Civil Sevice Form No. 08 Civil Sevice Form No. 08
DAILY TIME RECORD DAILY TIME RECORD
(NAME) (NAME)
For the month of For the month of
Official hours for arrival ( Regular days 8:00 AM-5:00PM Official hours for arrival ( Regular days 8:00 AM-5:00PM
and departure ( Saturdays and departure ( Saturdays
A.M. P.M. UNDERTIME A.M. P.M. UNDERTIME
DAY DAY
Arrival Depar- ture Arrival Depar- ture Hours Minutes Arrival Depar- ture Arrival Depar- ture Hours Minutes
1 1
2 2
3 3
4 4
5 5
6 6
7 7
8 8
9 9
10 10
11 11
12 12
13 13
14 14
15 15
16 16
17 17
18 18
19 19
20 20
21 21
22 22
23 23
24 24
25 25
26 26
27 27
28 28
29 29
30 30
31 31
TOTAL TOTAL
I CERTIFY on my honor that the above is a true and correct report of the hours of work I CERTIFY on my honor that the above is a true and correct report of the hours of work
perform, record of which was made daily at the time of arrival and departure from office. perform, record of which was made daily at the time of arrival and departure from office.
Verified as to the prescribed office hours. Verified as to the prescribed office hours.
MLGOO MLGOO
(See Instructions on back) (See Instructions on back)
