Appendix __

Fund :
LGU
Date :
DISBURSEMENT VOUCHER DV No. :

Classification of Disbursement
Cash Advance Reimbursement Other Payments

TIN/Employee No. CAFOA No.

Payee

Address

Responsibility
Particulars MFO/PAP Amount
Center

Amount Due:
A. Certified: Expenses/Cash Advance necessary, lawful and incurred under my direct supervision.

Printed Name, Designation and Signature

Head of the Department or Office

B. Accounting Entry:
Account Title Account Code Debit Credit

C. Certified: D. Approved for Payment

Cash available

Subject to Authority to Debit Account (when applicable)

Su
proper

Signature Signature

Printed
Printed Name
Name

Position Position
Head, Accounting Unit/Authorized Representative Agency Head/Authorized Representative

Date Date

E. Receipt of Payment
Check/ Date : Bank Name & Account Number:
ADA No. :
Date : Printed Name: Date
Signature :
Official Receipt No. & Date/Other Documents

90
REYNALDO A. FERATERO,MD,FPCS