Period Covered ________________ Date: _____________________
Responsibility Center Code:
Entity Name : _____________________________________________ Fund Cluster : _____________________________________________ __________________________
PARTICULARS AMOUNT
TOTAL AMOUNT SPENT
AMOUNT OF CASH ADVANCE PER DV NO.______DTD. ______ AMOUNT REFUNDED PER OR NO. ________DTD. ___________ AMOUNT TO BE REIMBURSED A Certified: Correctness of the B Certified: Purpose of travel / C Certified: Supporting above data cash advance duly accomplished documents complete and proper