Appendix 3

Fund Cluster :
Entity Name
Date :
DISBURSEMENT VOUCHER DV No. :

Mode of
Payment MDS Check Commercial Check ADA Others (Please specify)
_________________
TIN/Employee No.: ORS/BURS No.:
Payee

Address

Particulars Responsibility Center MFO/PAP Amount

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

________________________________________
Deputy Administrator for RDB

B. Accounting Entry:
Account Title UACS Code Debit Credit

C. Certified: D. A Approved for Payment

Cash available

Subject to Authority to Debit Account (when applicable)

Supp
proper

Signature Signature

Printed
Printed Name
Name
 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
 Appendix 32
Fund Cluster :

Date :
DV No. :

____________
ORS/BURS No.:

Amount

Credit
horized Representative