Annex B

Republic of the Philippines

LUNA (Isabela) WATER DISTRICT
Mambabanga, Luna, Isabela
CCC NO. 460
No.

DISBURSEMENT VOUCHER
Mode of
Check Cash Others
Payment
TIN/Employee No. Obligation Request No.
Payee
Responsibility Center
Office/Unit/Project Code
Address

EXPLANATION AMOUNT

A. Certified B. Certified
Allotment obligated for the purpose as indicated above Funds Available
Supporting documents complete

Signature Signature

Printed Date Date

Printed Name
Name

Position Position
Head, Accounting Unit/Authorized Representative Treasurer/Authorized Representative
C. Approved for Payment D. Received Payment
Check No. Bank Name Date
Signature

Date Signature
Printed
Name Printed Name Date
OR/Other Documents JEV No. Date
Position
Agency Head/Authorized Representative
 DISBURSEMENT VOUCHER (DV)
INSTRUCTIONS
A. The DV shall be printed in one whole sheet of
81/2 x 11 size bond paper. This shall be prepared
in three copies to be distributed as follows:
Original – Accounting Unit
Duplicate – Cash Unit
Triplicate – Payee
B. The Accounting Unit shall stamp the date of
receipt on the face of this form.
C. This form shall be accomplished in the
following manner:
1. DV No. – number assigned to the DV by the
Accounting Unit. It shall be numbered as
follows:
0000 00 0000
Serial number
(one series for each year )
Month
Year
2. Mode of Payment – put a check "" mark in
the appropriate box opposite the mode of
payment
3. Payee – name of the payee or creditor
4. TIN/Employee No. – Tax Identification
Number (TIN) of the claimant/Identification
Number assigned by the agency to the
officer/employee
5. Obligation Request No. – Number of the
obligation request supporting the DV
6. Address – address of the claimant
7. Responsibility Center (Office/Unit/Project
and Code) – the office/unit/project and code
assigned to the cost center where the
disbursement shall be charged
8. Explanation – brief description of the
disbursement
9. Amount – amount of claim
BACK
10. Certified (Box A) – certification of the Head
of Accounting Unit or his authorized
representative as to obligation of allotment
for the purpose as indicated and
completeness of supporting documents
The certifying officer shall affix his
signature, print his name, indicate his
position, and the date of his signing on the
spaces provided.
11. Certified (Box B) – certification by the
Treasurer or his Authorized Representative
on the availability of fund.
The certifying officer shall affix his
signature, print his name, indicate his
position, and the date of his signing on the
spaces provided.
12. Approved for Payment (Box C) – approval
by the Agency Head or his Authorized
Representative on the payment covered by
the DV.
The approving officer shall affix his
signature, print his name, indicate his
position, and the date of his signing on the
spaces provided.
13. Received Payment (Box D) –
acknowledgment by the claimant or his duly
authorized representative for the receipt of
the check/cash and the date of receipt. The
claimant/payee shall affix his signature on
the spaces provided and shall indicate the
number and the date of the check, bank name
and number and date of OR/other relevant
documents issued to acknowledge the receipt
of payment.
14. JEV No. and Date – Number and date of the
Journal Entry Voucher