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LIQUIDATION REPORT No.

Date
Responsibility Center
(Agency Name)

Particulars Amount

TOTAL
AMOUNT OF CASH ADVANCE
ERROR IN RECORDING
AMOUNT BALANCE
TOTAL BALANCE FORWARDED
A Certified: Correctnes of the B Certified: Purpose of cash C Certified: Supporting documents
above data advance duly accomplished complete and proper

Name of Principal District Supervisor Administrative Assistant III JEV No.

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