General Form No.

74 – A Annex E

REPUBLIC OF THE PHILIPPINES

Commission on Audit
REPORT OF CASH EXAMINATION
Name of Accountable Officer: IRENE V. MANANSALA Position/Designation: ADMINISTRATIVE OFFICER I
Agency: PROVINCIAL GOVERNMENT OF PAMPANGA Station: ROMANA PANGAN DISTRICT HOSPITAL
Maximum Accountability: Amount of Bond: Risk No.: Effective Date:
467,000.00 350,250.00 0354-2023-00791N 07/31/2022 to 07/30/2023
AUDITOR/EXAMINER: Official Designation:
TIFANNY C. REQUINE-TIPAY STATE AUDITOR II
A. CASH PRODUCTION NOTICE
TO: Accountable Officer: Position/Designation: Date:
IRENE V. MANANSALA ADMINISTRATIVE OFFICER I JULY 04, 2023
DEMAND, is hereby made that you produce all your cash, checks, money orders, cash items, paid vouchers, and/or unused accountable forms,
etc., for which you are officially accountable as CASHIER of the PROVINCIAL GOVERNMENT OF PAMPANGA – ROMANA
PANGAN DISTRICT HOSPITAL and any fund, checks, and/or cash items in your possession held by you for deposit and safekeeping.
Accountable Officer’s Signature: Date: Auditor/Examiner’s Signature:
NOTED AND COMPLIED WITH
JULY 04, 2023
B. CASH COUNT
INVENTORY OF CASH ON HAND INVENTORY OF CASH ITEMS (Include checks, treasury warrants, money orders, etc.)
Paper and Coin Amount
No. of Particulars
Denomination Amount Presented Allowed Disallowed
Pcs.
Bills:
1,000.00 8 P 8,000.00
500.00 4 2,000.00 n/a n/a n/a
200.00 1 200.00
100.00 35 3,500.00
50.00 24 1,200.00
20.00 12 240.00
Coins: Reviewed by:
10.00 2 20.00
5.00 41 205.00
1.00 58 58.00
0.50 - - ELEONOR D.C. LUNA
0.25 1 0.25 State Auditor IV
0.05 - - Audit Team Leader
0.01 - -
Total As Presented P Total n/a n/a n/a
TOTAL INVENTORY OF CASH/OR ALLOWED CASH ITEMS (TOD) P 117,551.00
C. INVENTORY OF UNUSED ACCOUNTABLE FORMS
With Money Value at cost Without Money Value
Inclusive Inclusive
Name of Form Qty. Denomination Amount Name of Form Qty.
Serial No. Serial No.

Accountable Form no. 2394463 to

n/a 12,038 pcs
51C 2406500

TOTAL
CERTIFICATION
I HEREBY CERTIFY on my official oath: (1) That upon demand by the Auditor/Examiner I produced all my cash, checks, money orders,
cash items, paid vouchers, unused accountable forms, etc., for which I am officially accountable; (2) That the Inventory of such cash, cash items
and unused accountable forms in my possession and produced to the Auditor/Examiner at the time of cash count today, JUNE 06, 2023 is
correctly stated above and is broken down as follows:

Cash and/or cash P117,551.00

items…………………………………………
Unused accountable forms with money n/a
value………………….
Unused accountable forms without money 12,038 pcs
value………………

of which (P 0.00) was disallowed by the Auditor/Examiner and (3) That said cash, checks, money orders, cash items, paid vouchers, unused
accountable forms, etc., were returned to me intact after the cash count.
Accountable Officer’s Signature: Position/Designation: Agency/Station:
ADMINISTRATIVE AIDE III / PROVINCIAL GOVERNMENT OF PAMPANGA
CASHIER / DOMINGO B. FLORES DISTRICT HOSPITAL
SIGNED IN THE PRESENCE OF:
 Witness’ name and signature: Witness’ name and signature:

D. STATEMENT OF ACCOUNTABILITY
REGULAR AND CONSIGNMENT
NATURE OF FUNDS
COLLECTIONS
Balance, last Cash Examination (March 10, 2022) 13,835.20
ADD: Debits to Accountability
March 10 to 31, 2022 4,876,075.37
April 2022 2,861,067.30
May 2022 5,556,840.69
June 2022 4,566,393.99
July 2022 5,606,034.94
August 2022 12,923,404.19
September 2022 5,764,324.72
October 2022 21,879,027.74
November 2022 8,516,316.60
December 2022 11,443,017.78
January 2023 9,794,892.31
February 2023 7,875,623.10
March 2023 7,873,202.06
April 2023 6,029,584.61
May 2023 8,376,627.85
June 01 to 04, 2023 1,812,625.15
June 05, 2023 – Undeposited Collections, included in the Cash Count 81,475.00
June 06, 2023 – Date of Cash Examination 36,076.00
Total Debits to Accountability 125886444.60
LESS: Credits to Accountability
March 11 to 31, 2022 4,803,916.37
April 2022 2,431,422.80
May 2022 5,957,250.84
June 2022 4,592,960.34
July 2022 5,511,636.04
August 2022 10,199,801.84
September 2022 7,915,258.75
October 2022 5,964,230.21
November 2022 25,072,090.75
December 2022 11,408,575.68
January 2023 9,794,532.61
February 2023 7,898,739.90
March 2023 7,071,229.96
April 2023 4,154,599.40
May 2023 11,117,388.66
June 01 to 05, 2023 1,875,259.45
Total Credits to Accountability 377541782.80
Balance of Accountability as of June 06, 2023 117,551.00
Inventory of Cash and/or allowed Cash Items 117,551.00
Shortage or (Overage) 0.00
 CERTIFICATION

I HEREBY CERTIFY that my accountability for the above funds of the PROVINCIAL GOVERNMENT OF PAMPANGA –
DOMINGO B. FLORES DISTRICT HOSPITAL at the time of the examination on JUNE 06, 2023 is correctly stated above totaling
ONE HUNDRED SEVENTEEN THOUSAND FIVE HUNDRED FIFTY-ONE PESOS (₱117,551.00)

Accountable Officer’s Signature: Position/Designation: Agency/Station:

PROVINCIAL GOVERNMENT OF
ADMINISTRATIVE AIDE III /
PAMPANGA / DOMINGO B. FLORES
CASHIER
DISTRICT HOSPITAL
I HEREBY CERTIFY that the preceding is a true and correct report of the examination of the Cash and Accounts of:
Name of Accountable Officer: Position/Designation: Agency/Station: Date
PROVINCIAL GOVERNMENT OF
ADMINISTRATIVE AIDE III /
MARY ROSE H. PANGAN PAMPANGA / DOMINGO B. FLORES JUNE 06, 2023
CASHIER
DISTRICT HOSPITAL
Remarks:

There was no overage/shortage noted during the Cash Examination. Noted deficiencies were on the late remittances of collections to
the Provincial Treasurer’s Office and the incorrect preparation of the Report on Accountability for Accountable Forms. These
observations are discussed thoroughly in Part II of the Narrative Report.

Signature of Auditor/Examiner: Date: JUNE 06, 2023

INSTRUCTIONS
1. This form will be used for the examination of all cash accountable officers in the corporate, national and local government
officers.
2. Before proceeding to conduct an examination, the examiner should thoroughly familiarize himself with the revised manual on
cash examination.
3. The six (6) columns on the face hereof are left blank to meet all fund requirements.
4. If space provided for is not enough, use it as summary only and support it with schedules.
5. All reports of examination with their supporting papers and letters will be forwarded to their respective Regional Directors in
duplicate. In the event of shortage\irregularity, the procedures outlined under COA Memorandum 83-81B dated November 1983
should be strictly followed.
6. Checks, treasury warrants, money orders, and other cash items shall be listed on the space for Inventory of Cash Items.