Travel Format

Republic of the Phillippines
DEPARTMENT OF THE INTERIOR AND LOCAL GOVERNMENT

Region III, Government Center, Maimpis, City of San Fernando, Pampanga
OBLIGATION REQUEST No.
Payee AIRA MAY T. BALANCIO
Office DILG REGIONAL OFFICE III
Address
Responsibility Account
Center Particulars P.P.A. Code Amount
To reimburse payment of travelling expenses incurred while on
official travel for the period of September 22, November 4-6,
November 10-13, November 17-21, and November 30-December
1, 2014 as per supporting papers hereto attached in the amount
of …..….
3,600.00
Total 3,600.00
A. Certified B Certified
Charges to appropriation/allotment necessary, lawful Allotment
B. available and obligated for the
and under my direct supervision purpose as indicated above
Supporting documents valid, proper and legal.
Signature Signature
Printed name ANITA W. ADRIANO Printed Name RINA G. MALLARI
Chief, Finance and Administrative Division Budget Officer III
Position Position
Head, Requesting Office/ Authorized Representative
Date Date

Address
of …..…. 3,600.00
Total 3,600.00
Certified B Certified
A.
Signature Signature
Position Position
Date Date
Address
of …..….
Total -
A. Certified B Certified
Signature Signature
Position Position
Date Date
DEPARTMENT OF INTERIOR AND LOCAL GOVERNMENT Fund Cluster :
Entity Name
Date :
DISBURSEMENT VOUCHER DV No. :
Mode of MDS Check Commercial Check ADA Others (Please specify)

Payment
_________________
ORS/BURS No.:
Payee JUAN DELA CRUZ
Address TARLAC CITY
Responsibility
Particulars MFO/PAP Amount
Center
500.00
To reimburse payment of travelling expenses incurred while
on official travel for the period of JULY,2022Sas per
supporting papers hereto attached in the amount of ….
Amount Due 500.00

A. Certified: Expenses/Cash Advance necessary, lawful and incurred under my direct supervision.
NAME Of MLGOO
MLGOO
Printed Name, Designation and Signature of Supervisor
B. Accounting Entry:
Account Title UACS Code Debit Credit
COMMUNICATION 5020101000 500
CASH IN BANK 1010202024 500

C. Certified: D. Approved for Payment
Cash available
Subject to Authority to Debit Account (when applicable)
500.00
Sup
proper
Signature Signature
Printed
Printed Name
Name LENOR CANDICE U. DE GUZMAN ARMI V. BACTAD, CESO V
ADAS 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. :
Date : Printed Name: Date
Signature :
Official Receipt No. & Date/Other Documents
DISBURSEMENT VOUCHER No.
Mode of
MDS Check Commercial Check ADA Others
Payment
TIN/Employee No. OR/BUR No.
Responsibility Center
Address CSFP Office/Unit/Project Code
EXPLANATION AMOUNT
To reimburse payment of travelling expenses incurred while on official travel for the period of
September 22, November 4-6, November 10-13, November 17-21 and November 30-
December 1, 2014 as per supporting papers hereto attached in the amount of …..…. 3,600.00
A. Certified B. Approved for Payment

Cash Available
Supporting documents complete
Signature Signature
Printed Printed
JEAN HAZEL P. BACANI FLORIDA M. DIJAN DPA, CESO III
Name Name
Position OIC-Regional Accountant Position Regional Director
Date Date
C. Received Payment JEV No.
C.
Check/ ADA Date Bank Name
No.
Signature Date Printed Name Date
Official Receipt/Other Documents

Mode of
Payment
Payee TIN/Employee No. OR/BUR No.
AIRA MAY T. BALANCIO
EXPLANATION AMOUNT
September 22, November 4-6, November 10-13, November 17-21 and November 30-
December 1, 2014 as per supporting papers hereto attached in the amount of …..….
3,600.00

Cash Available
Signature Signature
Printed Printed
Name Name
Date Date
C.
No.

Mode of
Payment
Payee MARIEL V. ESTACIO TIN/Employee No. OR/BUR No.
EXPLANATION AMOUNT
July 12, 16, 19, Sept. 04, 06, 11, 2012 as per supporting papers hereto attached in the 2,400.00
amount of ….

Cash Available
Signature Signature
Printed Printed
Name Name
Date Date
C.
No.
C.
A.
C
A. MDS Check Commercial Check
B.
B. ADA Others
C.

Mode of
Payment
Payee MARIEL V. ESTACIO TIN/Employee No. OR/BUR No.
EXPLANATION AMOUNT
Aug. 23, 24, 29, 30, 31, Sept. 13, 14, 25, 27, 2012 as per supporting papers hereto attached 2,400.00
in the amount of ….

Cash Available
Signature Signature
Printed Printed
ALEXANDER N. ABENOJA FLORIDA M. DIJAN, DPA, CESO IV
Name Name
Position Chief Accountant Position Regional Director
Date Date
C.
No.
Republic of the Philippines
Zamora Street, San Roque, Tarlac City, Tarlac
ITINERARY OF TRAVEL
Name : JUAN DELA CRUZ Date:
Station: DILG TARLAC Position: CONTACT TRACER
Purpose of Travel:
See attached Regional Order/Travel Order
TIME MEANS OF ALLOWANCE EXPENSE
DATE STATION DEPARTURE ARRIVAL TRANSPOR- TRANSPOR- PER OTHERS TOTAL
TATION TATION DIEM
TOTAL 500.00
Prepared by:
I certify that : (1) have reviewed the foregoing itinerary,
(2) the travel is necessary to the service, (3) the period
covered is reasonable and (4) the expenses claimed JUAN DELA CRUZ
are proper. Signature over Printed Name
Approved by:
NAME OF MLGOO
Signature over Printed Name
Immediate Supervisor ARMI V. BACTAD, CESO V
Signature over Printed Name
Ageny Head/Authorized Representative
CERTIFICATE OF TRAVEL COMPLETED
DILG TARLAC CITY, TARLAC

Station
Date
This is to certify that I have completed the travel authorized in the itinerary of travel dated
as to the under conditions indicated below:
x Strictly in accordance with the approved itinerary
Cut short as explained below. Excess payment in the amount of

as retured OR # dated
Extended as explained below, additional itinerary was submitted.
Explanations or Justifications :
Evidence of travel hereto attached: Certificate of Appearance , Itinerary of Travel, OB Slip,
Respectfully submitted:
JUAN DELA CRUZ

Contact Tracer
On evidence, information of which I have knowledge, the travel was completely undertaken.
ARMI V. BACTAD, CESO V

Provincial Director
FIELD DIARY / ACCOMPLISHMENT REPORT
Name: JUAN DELA CRUZ Position/Designation: Contact Tracer

Official Station: DILG TARLAC Person(s) Contacted:
Purpose of Travel:
Please see attached approved OB Slip
Activities (Enumerate)
1
2
3
4
5
6
7
8
9
10
Accomplishments( Quantity/ Explain Briefly)

All purpose of each travel authorities were done successfully.
Issues/Problems encountered
1
2
3
4
5
Comments/ Recommendations:
1
2
3
4
5
Submitted by: Noted by:
JUAN DELA CRUZ ARMI V. BACTAD, CESO V

Contact Tracer Provincial Director

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Republic of the Phillippines

DEPARTMENT OF THE INTERIOR AND LOCAL GOVERNMENT

Republic of the Phillippines

Mode of MDS Check Commercial Check ADA Others (Please specify)

Address TARLAC CITY

Amount Due 500.00

CASH IN BANK 1010202024 500

E. Receipt of Payment JEV No.

A. Certified B. Approved for Payment

Official Receipt/Other Documents

Republic of the Phillippines

A. Certified B. Approved for Payment

Official Receipt/Other Documents

A. Certified B. Approved for Payment

Republic of the Phillippines

A. Certified B. Approved for Payment

CERTIFICATE OF TRAVEL COMPLETED

DILG TARLAC CITY, TARLAC

as to the under conditions indicated below:

x Strictly in accordance with the approved itinerary

Cut short as explained below. Excess payment in the amount of

Extended as explained below, additional itinerary was submitted.

Evidence of travel hereto attached: Certificate of Appearance , Itinerary of Travel, OB Slip,

JUAN DELA CRUZ

ARMI V. BACTAD, CESO V

FIELD DIARY / ACCOMPLISHMENT REPORT

Name: JUAN DELA CRUZ Position/Designation: Contact Tracer

Accomplishments( Quantity/ Explain Briefly)

Submitted by: Noted by:

JUAN DELA CRUZ ARMI V. BACTAD, CESO V

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