Department of Education

Region VI - Western Visayas name of school

Schools Division of Capiz
District of Cuartero

SAN ANTONIO NATIONAL HIGH SCHOOL year-date (ex: 2018-01)

No.:

For the Period July to September 2022

CHECK DISBURSEMENTS REGISTER
TYPE OF WORKING FUND: MOOE

CASH ADVANCE BREAKDOWN OF PAYMENTS

REFERENCE OFFICE TELEPHONE R&M - OTHER ACCOUNTS
DATE (OR/RER/ PAYEE / AMOUNT BALANCE TRAVEL SUPPLIES WATER ELECTRICITY EXPENSES SECURITY SCHOOL ACCOUNT ACCOUNT
Account codes:
date cash received
Check No. PARTICULARS RECEIVED PAYMENTS (6=4-5) EXPENSES EXPENSES EXPENSES EXPENSES - MOBILE SERVICES BUILDINGS NAME CODE AMOUNT
(5020101000) (5020301000) (5020401000) (5020402000) (5020502000) (5021203000) (5021304002) Other Mooe ---------- 5029999099
(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16)
Other Supplies Exp -- 5020399000
-
Fidelity Bond Exp ---- 5021502000
- Printing exp ---------- 5029902000
- R&M-ICT ------------- 5021305003
Mobile Expenses ----- 5020502001
-
Internet Sub. Exp --- 5020503000
- Training Exp --------- 5020201000
- Janitorial Expense --- 5021202000
-

- - - - - - - - - - -

CERTIFIED CERTIFIED:
date liquidated NOTED:
CORRECT: SUPPORTING DOCUMENTS COMPLETE

ANALEA E. FUENTES ATTY. BENJIE B. DOCE, CPA, MBA MIGUEL MAC D. APOSIN EdD, CESO V
SCHOOL HEAD / DISBURSING OFFICER Accountant III SCHOOLS DIVISION SUPERINTENDENT

DATE DATE DATE

 No. :
LIQUIDATION REPORT Date:
Department of Education Responsibility Center:

PARTICULARS AMOUNT

Expenses Incurred:

Liquidation of ___________________ - ____________________

for the month of __________________________________
cash advance as per Dv No. _______ dated __________
in the amount of ……………………………………… P

TOTAL AMOUNT SPENT -

AMOUNT OF CASH ADVANCE : DV No. DTD. / /201 -
AMOUNT REFUNDED PER OR NO. __________________ DTD. ___________ 0.00
AMOUNT TO BE REIMBURSED 0.00
A. Certified: Correctness of the B Certified: Purpose of travel/Cash C Certified: Supporting documents
above data. advance duly accomplished complete and proper

ANALEA E. FUENTES ROEL F. BERMEJO, CESO V ATTY. BENJIE B. DOCE, CPA, MBA _____
School Head Schools Division Superintendent Accountant III JEV No.
 USE IF THE CASH
ADVANCE IS
UNDER YOUR
NAME

_____
JEV No.
 REQUISITION AND ISSUE SLIP
Department of Education
(Agency)

Division: CAPIZ Responsibility Center RIS No.

School: Code _________________ SAI No.

Requisition Iss
Stock No. Unit Description Quantity Quantity
Stock No.:
1
2 1 pcs LONG PLASTIC ENVELOPE 30 30
3 2 boxes CRAYONS 30 30
4 3 pcs GLUE 30 30
5 4 pad PAPER 20 20
5 pcs PENCIL 30 30
6 pcs BALLPEN 30 30
7 pcs PENCIL ERASER 30 30
8 bot EPSON 664 BLK 5 5
9 bot EPSON 003 INK BLK 20 20
10 bot EPSON 003 INK M 15 15
11 bot EPSON 003 INK CY 15 15
12 bot EPSON 003 INK Y 14 14
13 boxes CHALK - DUSTLESS 12 12
14 box STAPLE WIRE 10 10
15 pcs SIGN PEN BLACK 11 11
16 pcs SIGN PEN BLUE 11 11
17 pcs SIGN PEN RED 10 10
18 pcs SCOTCH TAPE 10 10
19 pcs BROAD PENTEL PEN 1 1
20 pcs FINE PENTEL PEN 1 1
21 pcs PENTEL PEN INK 10 10

Purpose : Payment for the purchase of various office supplies for the conduct of Nation
2023.

Requested by: Approved by: Issued by:

Signature
Name JASON B. PORTADA ANALEA E. FUENTES TAMMY B. ESTORQUE
Designation Administrative Assistant - II School Head Property Custodian
Date

strictly school head and property

custodian
strictly school head and property
custodian
AND ISSUE SLIP
of Education 070010806003
gency)

Date
Date

Issuance
fill-in "Complete"
Quantity Remarks

30 Complete
30 Complete
30 Complete
20 Complete
30 Complete
30 Complete
30 Complete
5 Complete
20 Complete
15 Complete
15 Complete
14 Complete
12 Complete
10 Complete
11 Complete
11 Complete
10 Complete
10 Complete
1 Complete
1 Complete
10 Complete

upplies for the conduct of National Learning Camp

Received by:

TAMMY B. ESTORQUE JASON B. PORTADA

whoever requested will be the
Property Custodian Administrative Assistantone
- II to receive.
 PURCHASE REQUES
Department of Educatio
(Agency)

Division : CAPIZ PR No. :

School : SAI No. :

Stock No. Unit Description

Stock No.:
1 1 pcs LONG PLASTIC ENVELOPE
2 2 boxes CRAYONS
3 3 pcs GLUE
4
5
4 pad PAPER
5 pcs PENCIL
6 pcs BALLPEN
7 pcs PENCIL ERASER
8 bot EPSON 664 BLK
9 bot EPSON 003 INK BLK
10 bot EPSON 003 INK M
11 bot EPSON 003 INK CY
12 bot EPSON 003 INK Y
13 boxes CHALK - DUSTLESS
14 box STAPLE WIRE
15 pcs SIGN PEN BLACK
16 pcs SIGN PEN BLUE
17 pcs SIGN PEN RED
18 pcs SCOTCH TAPE
19 pcs BROAD PENTEL PEN
20 pcs FINE PENTEL PEN
21 pcs PENTEL PEN INK

Total
Purpose : Payment for the purchase of various office supplies fo
Camp 2023.

Requested by:

Signature :
Name : TAMMY B. ESTORQUE
Designation : Property Custodian

strictly Property Custod

strictly Property Custod
PURCHASE REQUEST
Department of Education
(Agency)

fill-in date
Date :
Date :

Quantity Unit Cost Total Cost

30 15.00 450.00 2 30.00

30 25.00 750.00 1 25.00
30 13.00 390.00 1 13.00
20 40.50 810.00 1 40.50
30 7.00 210.00 2 14.00
30 9.00 270.00 2 18.00
30 2.00 60.00 2 4.00
5 338.00 1,690.00 2 676.00
20 355.00 7,100.00 -
15 355.00 5,325.00 -
15 355.00 5,325.00 -
14 355.00 4,970.00 -
12 89.00 1,068.00 820.50
10 65.00 650.00
11 21.00 231.00
11 21.00 231.00
10 21.00 210.00
10 40.00 400.00 joven
1 497.00 497.00 jenny
1 500.00 500.00 delbrin
10 125.00 1,250.00

check total amount

32,387.00 31,739.26

arious office supplies for the conduct of National Learning

quested by: Approved :

B. ESTORQUE ANALEA E. FUENTES

strictly school head
rty Custodian School Head

strictly Property Custodian

strictly Property Custodian
72500
290

31,091.52
30,271.02
20,097.02

2000
4100
4074 3750 324
10174
 Department of Education
Region VI - Western Visayas
Schools Division of Capiz
SAN ANTONIO NATIONAL HIGH SCHOOL

Please quote your price for furnishing and delivering immediately following supplies and materials and/or articles
needed by the office of the School Division Superintendent for Capiz, city of Roxas under Req. and issue voucher dated
.

QUOTATION
QTY. UNIT ARTICLES
UNIT PRICE TOTAL PRICE

30 pcs LONG PLASTIC ENVELOPE

30 boxes CRAYONS
30 pcs GLUE
20 pad PAPER
30 pcs PENCIL
30 pcs BALLPEN
30 pcs PENCIL ERASER
5 bot EPSON 664 BLK
20 bot EPSON 003 INK BLK
15 bot EPSON 003 INK M
15 bot EPSON 003 INK CY
14 bot EPSON 003 INK Y
12 boxes CHALK - DUSTLESS
10 box STAPLE WIRE
11 pcs SIGN PEN BLACK
11 pcs SIGN PEN BLUE
10 pcs SIGN PEN RED
10 pcs SCOTCH TAPE
1 pcs BROAD PENTEL PEN
1 pcs FINE PENTEL PEN
10 pcs PENTEL PEN INK

Total

It is requested that the quotation by you be actually your lowest price and should include delivery of supplies/materials and/
articles to the site of work. Failure on the part of the bidder to deliver the supplies / materials / or articles within ten (10) days
from the date of the awrd and/or articles will be imposed on the bidder from each day of delay.
It is requested that your proposal be enclosed in a sealed envelope and delivered to this office to be opened at _____ o'clock
A.M./P.M. on __________ .

ANALEA E. FUENTES
School Head

I hereby certify that the prices above are the lowest price and that if accepted by the government the supplies/materials
and/or articles shall be delivered immediately.

Name and Signature of Bidder

 Department of Education
Region VI - Western Visayas
Schools Division of Capiz
SAN ANTONIO NATIONAL HIGH SCHOOL

Please quote your price for furnishing and delivering immediately following supplies and materials and/or
needed by the office of the School Division Superintendent for Capiz, city of Roxas under Req. and issue vouc
.

QUOTATION
QTY. UNIT ARTICLES
UNIT PRICE TOTAL PRICE

It is requested that the quotation by you be actually your lowest price and should include delivery of supplies/mate
articles to the site of work. Failure on the part of the bidder to deliver the supplies / materials / or articles within ten
from the date of the awrd and/or articles will be imposed on the bidder from each day of delay.
It is requested that your proposal be enclosed in a sealed envelope and delivered to this office to be opened at _____
A.M./P.M. on __________ .

ANALEA E. FUENTES
School Head

I hereby certify that the prices above are the lowest price and that if accepted by the government the supplie
and/or articles shall be delivered immediately.

Name and Signature of Bidder

 Department of Education
Region VI - Western Visayas
Schools Division of Capiz
SAN ANTONIO NATIONAL HIGH SCHOOL

Please quote your price for furnishing and delivering immediately following supplies and materials and/or
needed by the office of the School Division Superintendent for Capiz, city of Roxas under Req. and issue vouc
.

QUOTATION
QTY. UNIT ARTICLES
UNIT PRICE TOTAL PRICE

It is requested that the quotation by you be actually your lowest price and should include delivery of supplies/mate
articles to the site of work. Failure on the part of the bidder to deliver the supplies / materials / or articles within ten
from the date of the awrd and/or articles will be imposed on the bidder from each day of delay.
It is requested that your proposal be enclosed in a sealed envelope and delivered to this office to be opened at _____
A.M./P.M. on __________ .

ANALEA E. FUENTES
School Head

I hereby certify that the prices above are the lowest price and that if accepted by the government the supplie
and/or articles shall be delivered immediately.

Name and Signature of Bidder

 Department of Education
Region VI - Western Visayas
Schools Division of Capiz
SAN ANTONIO NATIONAL HIGH SCHOOL

Abstract of Bids for funishing for use in the which was

opened in the Office of the School Head of the said school at A.M./P.M.

BIDDERS PRICE
ARTICLES

LONG PLASTIC ENVELOPE 30 @ _______ / pcs = 30 @ _______ / pcs = 30 @ _______ / pcs =

CRAYONS 30 @ _______ / boxes = 30 @ _______ / boxes = 30 @ _______ / boxes =
GLUE 30 @ _______ / pcs = 30 @ _______ / pcs = 30 @ _______ / pcs =
PAPER 20 @ _______ / pad = 20 @ _______ / pad = 20 @ _______ / pad =
PENCIL 30 @ _______ / pcs = 30 @ _______ / pcs = 30 @ _______ / pcs =
BALLPEN 30 @ _______ / pcs = 30 @ _______ / pcs = 30 @ _______ / pcs =
PENCIL ERASER 30 @ _______ / pcs = 30 @ _______ / pcs = 30 @ _______ / pcs =
EPSON 664 BLK 5 @ _______ / bot = 5 @ _______ / bot = 5 @ _______ / bot =
EPSON 003 INK BLK 20 @ _______ / bot = 20 @ _______ / bot = 20 @ _______ / bot =
EPSON 003 INK M 15 @ _______ / bot = 15 @ _______ / bot = 15 @ _______ / bot =
EPSON 003 INK CY 15 @ _______ / bot = 15 @ _______ / bot = 15 @ _______ / bot =
EPSON 003 INK Y 14 @ _______ / bot = 14 @ _______ / bot = 14 @ _______ / bot =
CHALK - DUSTLESS 12 @ _______ / boxes = 12 @ _______ / boxes = 12 @ _______ / boxes =
STAPLE WIRE 10 @ _______ / box = 10 @ _______ / box = 10 @ _______ / box =
SIGN PEN BLACK 11 @ _______ / pcs = 11 @ _______ / pcs = 11 @ _______ / pcs =
SIGN PEN BLUE 11 @ _______ / pcs = 11 @ _______ / pcs = 11 @ _______ / pcs =
SIGN PEN RED 10 @ _______ / pcs = 10 @ _______ / pcs = 10 @ _______ / pcs =
SCOTCH TAPE 10 @ _______ / pcs = 10 @ _______ / pcs = 10 @ _______ / pcs =
BROAD PENTEL PEN 1 @ _______ / pcs = 1 @ _______ / pcs = 1 @ _______ / pcs =
FINE PENTEL PEN 1 @ _______ / pcs = 1 @ _______ / pcs = 1 @ _______ / pcs =
PENTEL PEN INK 10 @ _______ / pcs = 10 @ _______ / pcs = 10 @ _______ / pcs =

Total: Total: Total:

We hereby certify to the correctness of the above quotation of prices as per attached proposal of the above named bidders which were opened in the presence of :

TAMMY B. ESTORQUE JASON B. PORTADA

School Property Custodian Disbursing Officer

APPROVED for the purpose from dealer as checked above.

ANALEA E. FUENTES
School Head Name of Bidder Resident Auditor LEAVE BLANK
LEAVE BLANK
 which was

AVE BLANK
AVE BLANK
 Appendix 35

PURCHASE ORDER
Department of Education
SAN ANTONIO NATIONAL HIGH SCHOOL

AJM OFFICE AND SCHOOL SUPPLIES

Supplier : P.O. No.
TRADING
Brgy. Banica, Roxas City
Address : Date
TIN : 766-287-950-001 Mode of Procurement Shopping

Gentlemen:

Please furnish this office the following articles subject to the terms and conditions contained herein:

Place of Delivery: Delivery Term:

Date of Delivery: Payment Term:

Stock No. Unit Quantity Description Unit cost Amount

P P

1 pcs 30 LONG PLASTIC ENVELOPE 15.00 450.00

2 boxes 30 CRAYONS 25.00 750.00

3 pcs 30 GLUE 13.00 390.00

4 pad 20 PAPER 40.50 810.00

5 pcs 30 PENCIL 7.00 210.00

6 pcs 30 BALLPEN 9.00 270.00

7 pcs 30 PENCIL ERASER 2.00 60.00

8 bot 5 EPSON 664 BLK 338.00 1,690.00

9 bot 20 EPSON 003 INK BLK 355.00 7,100.00

10 bot 15 EPSON 003 INK M 355.00 5,325.00

11 bot 15 EPSON 003 INK CY 355.00 5,325.00

12 bot 14 EPSON 003 INK Y 355.00 4,970.00

13 boxes 12 CHALK - DUSTLESS 89.00 1,068.00

14 box 10 STAPLE WIRE 65.00 650.00

15 pcs 11 SIGN PEN BLACK 21.00 231.00

16 pcs 11 SIGN PEN BLUE 21.00 231.00

17 pcs 10 SIGN PEN RED 21.00 210.00

18 pcs 10 SCOTCH TAPE 40.00 400.00

19 pcs 1 BROAD PENTEL PEN 497.00 497.00

20 pcs 1 FINE PENTEL PEN 500.00 500.00

21 pcs 10 PENTEL PEN INK 125.00 1,250.00

(Total Amount in Words)

"Thirty Two Thousand Three Hundred Eighty Seven Pesos Only" P 32,387.00

In case of failure to make the full delivery within the time specified above, a penalty of one-tenth (1/10) of one (1) percent for
every day of delay shall be imposed.

Very truly yours,

Conforme:
ANALEA E. FUENTES
AJM OFFICE AND SCHOOL SUPPLIES TRADING SCHOOL HEAD
SUPPLIER

(Date)

Funds Available:
Amount: 32,387.00
JASON B. PORTADA
DISBURSING OFFICER ALOBS No.:

SCHOOL TREASURER
 INSPECTION AND ACCEPTANCE R
Department of Education
SAN ANTONIO NATIONAL HIGH SCHOOL

Supplier AJM OFFICE AND SCHOOL SUPPLIES TRADING

PO No. Date Invoice No.
Requisitioning Office/Dept.

Stock No. Unit Description

1 pcs LONG PLASTIC ENVELOPE

2 boxes CRAYONS

3 pcs GLUE

4 pad PAPER

5 pcs PENCIL
6 pcs BALLPEN
7 pcs PENCIL ERASER

8 bot EPSON 664 BLK

9 bot EPSON 003 INK BLK

10 bot EPSON 003 INK M

11 bot EPSON 003 INK CY

12 bot EPSON 003 INK Y

13 boxes CHALK - DUSTLESS

14 box STAPLE WIRE

15 pcs SIGN PEN BLACK

16 pcs SIGN PEN BLUE

17 pcs SIGN PEN RED

18 pcs SCOTCH TAPE

19 pcs BROAD PENTEL PEN

20 pcs FINE PENTEL PEN

21 pcs PENTEL PEN INK

INSPECTION AC

Date Inspected: Date Received:

Inspected, verified and found OK

as to quantity and specifications
 TAMMY B. ESTORQUE
PROPERTY CUSTODIAN

For Property Office Use

 Annex G-7

INSPECTION AND ACCEPTANCE REPORT

Department of Education
SAN ANTONIO NATIONAL HIGH SCHOOL

JM OFFICE AND SCHOOL SUPPLIES TRADING IAR No.

Date:

Description Quantity

LONG PLASTIC ENVELOPE 30

CRAYONS 30

GLUE 30

PAPER 20

PENCIL 30
BALLPEN 30
PENCIL ERASER 30

EPSON 664 BLK 5

EPSON 003 INK BLK 20

EPSON 003 INK M 15

EPSON 003 INK CY 15

EPSON 003 INK Y 14

CHALK - DUSTLESS 12

STAPLE WIRE 10

SIGN PEN BLACK 11

SIGN PEN BLUE 11

SIGN PEN RED 10

SCOTCH TAPE 10

BROAD PENTEL PEN 1

FINE PENTEL PEN 1

PENTEL PEN INK 10

ACCEPTANCE

Date Received:

Complete

Partial

(pls. Specify quantity)

ANALEA E. FUENTES
SCHOOL HEAD
 Department of Education
Region VI - Western Visayas
Schools Division of Capiz
SAN ANTONIO NATIONAL HIGH SCHOOL
District of ____________

LIST OF RECIPIENTS FOR TEST PAPERS

We, the teachers of _________________________________ acknowledge the following supplies:

NAME OF TEACHER GRADE LEVEL NO. OF COPIES RECEIVED SIGNATURE

Prepared by:

TAMMY B. ESTORQUE
Property Custodian

Noted:

ANALEA E. FUENTES
School Head
 Department of Education
Region VI - Western Visayas
Schools Division of Capiz
SAN ANTONIO NATIONAL HIGH SCHOOL
District of Cuartero

LIST OF RECIPIENTS FOR SUPPLIES

We, the teaching and non-teaching staff of __San Antonio National High School__ acknowledge the following supplies:

ITEMS RECEIVED
NAME LONG
PENCIL EPSON
EPSON EPSON EPSON
EPSON CHALK - STAPLE
SIGN SIGN
SIGN SCOTCH
BROAD FINE
PENTEL SIGNATURE
PLASTIC GLUE PAPER PENCIL 003 INK 003 INK 003 INK PEN PEN PENTEL PENTEL
CRAYONS BALLPEN ERASER 664 BLK 003 INK Y DUSTLESS WIRE PEN RED TAPE PEN INK
ENVELOPE BLK M CY BLACK BLUE PEN PEN

LOVELY B. DELFIN 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 1 1 1 0 0 1

JULIE ANN D. ILI 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 1 1 1 0 0 1

LEVY D. BANDIOLA 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 1 1 1 0 0 1

IRENE D. CABACHETE 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 1 1 1 0 0 1

ALDEN M. DACLES 5 5 5 5 5 5 5 0 0 0 0 0 1 1 1 1 1 1 0 0 1

EDEN GRACE F. DUMAGPI 7 7 7 7 7 7 7 0 0 0 0 0 1 1 1 1 1 1 0 0 1

JENNY A. DASA 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 1 1 1 0 0 1

TAMMY B. ESTORQUE 3 3 3 3 3 3 3 0 0 0 0 0 1 1 1 1 1 1 0 0 1
HANNAH F. CARBONEL 4 4 4 4 4 4 4 0 0 0 0 0 1 1 1 1 1 1 0 0 1

MARIAN ERA B. HORLADOR 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 1 1 1 0 0 1

STOCK ROOM 11 11 11 1 11 11 11 5 20 15 15 14 2 0 1 1 0 0 1 1 0

Prepared by:

TAMMY B. ESTORQUE
Property Custodian

Noted:

ANALEA E. FUENTES
School Head
 Department of Education
Region VI - Western Visayas
Schools Division of Capiz
SAN ANTONIO NATIONAL HIGH SCHOOL
District of ____________

LIST OF ITEMS HAULED

We, the teachers of _________________________________ acknowledge the following supplies/materials:

ITEMS RECEIVED
ITEMS
DESCRIPTION QUANTITY

Prepared by:

Property Custodian

Noted:

School Head
INDICATE
QUANTITY AND
NAME OF ITEMS
 Appendix 59

INVENTORY CUSTODIAN SLIP

Entity Name:
Fund Cluster : ICS No :

Amount
Inventory Estimated
Quantity Unit Total Description
Unit Cost Item No. Useful Life
Cost

Received from: Received by:

End-user or the pers
TAMMY B. ESTORQUE PROPERTY CUSTODIAN JASON B. PORTADA who requested
Signature Over Printed Name Signature Over Printed Name
Property Custodian
Position/Office Position/Office

Date Date
End-user or the person
who requested
 PROPERTY ACKNOWLEDGMENT

Entity Name :
Fund Cluster:

Quantity Unit Description

end-user (or kung sin-o

ang mabaton sang
property)

Received by: Received from:

Signature Over Printed Name

Position / Office

Date
 Appendix 71

for printer, e-fan,

Y ACKNOWLEDGMENT RECEIPT laptop, tv, ref, rice
cooker

PAR No.:

Property Date
Amount
Number Acquired

Received from:
Property Custodian
only
TAMMY B. ESTORQUE
Signature Over Printed Name

PropertyCustodian
Position / Office

Date
 Revised January 1992

REIMBURSEMENT EXPENSE RECEIPT

Date: No.

Received from LOURDES V. PALIGUMBA

(Name of School Head)

of SAN ANTONIO NATIONAL HIGH SCHOOL

(Name of School)

of
(In Words)

(payments for subsistence, services, rental or transportation

should show inclusive date, purpose, distance, inclusive points of travel)

etc. __________________________________________________________________

WITNESS PAYEE
witness should be
Treasurer Name/Signature:
Address:
Res.Cert./Contact No.:
Date of Issue:
Place of Issue:
IMBURSEMENT EXPENSE RECEIPT
don't forget the RER no.

LOURDES V. PALIGUMBA
(Name of School Head)

the amount

(In Figure)
Specify distance if
travel, rate if labor

subsistence, services, rental or transportation

e date, purpose, distance, inclusive points of travel)

___________________________________________

PAYEE

fill-in contact no. of

witness & payee
General Form No. 7(A) TIME BOOK AND PAYROLL
Revised August, 1984

For labor on ___________________________________________________________________________, at __________________________________________ Philippines, for the period _______________________, 20_______ to ________________ ,20_______
(state job or project on which labor was performed)

TIME ROLL
(Mark time each day under proper date RESIDENCE CERTIFICATE /
WAGES DEDUCTIONS
SIGNATURE OR THUMB CONTACT NUMBER SIGNATURE OF
No. NAME OCCUPATION
using fraction when necessary) MARK WITNESS

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 NUMBER
Term Total Net Amount
OF DAYS Rate Per Day TOTAL AMOUNT Insurance
Medicare
Deductions Due NUMBER DATE Place of Issue
16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 WORKED

10

TOTAL
2. I CERTIFY that this roll is correct, every person whose name appears hereon
1. HEREBY CERTIFY that each person whose name appears on this roll 6. I CERTIFY on my official oath that I have this __________ day of __________, _____ paid in cash to each
rendered service for the time and at the rates stated, under my general
rendered service as indicated and for the time stated. man whose name appears on the above roll, the amount set opposite his name, he having presented himself,
supervision, and I approve payment of this roll.
established his identity, and affixed his signature or thumb mark on the space provided therefore Unpaid
services are indicated by red ink through the column "Amount Paid."
ANALEA E. FUENTES
Industrial Arts Teacher School Head

"NOTE: - Where thumb mark is to be used in place of signature and the space available is not sufficient the thumb mark may be impressed on the back hereof with proper indication of the corresponding laborer's number and on the
School Treasurer
corresponding line on the payroll a remark "See thumb mark on the back" should be written.
 Department of Education
Region VI - Western Visayas
Schools Division of Capiz
SAN ANTONIO NATIONAL HIGH SCHOOL

JOB ORDER

Job Order No.: don't for

Date:

To:

Completion time from this date the job order is received by the contractor

fill-in tim

Item No. Explanation/Description/Specification:

Wages of Laborers for the period:

specify rate per day or if pakyaw
Nature of Work:

1.
2. specify work to be done
3.

Obligation No.:

Funds Available:

Approved:

ANALEA E. FUENTES
School Head

Accepted:

0
 don't forget J.O. No.

fill-in time frame

r if pakyaw
 Department of Education
Schools Division of Capiz
SAN ANTONIO NATIONAL HIGH SCHOOL

PROGRAM OF WORK

I. Name of Project:
II. Project Location:
III. Project Proponent:
IV. Project Beneficiaries:
V. Source of Fund:
VI. Time Frame:

VII. Budget Proposals:

A. Materials:
Quantity Unit Description Unit Cost Total Cost
-
-
-
-
-
-
-
-
-
-
-
-
-
Total: -

B. Labor:

Total - 30-35% labor

Prepared by:

Industrial Arts Teacher

Noted:
strictly industri
ANALEA E. FUENTES
School Head
30-35% labor

strictly industrial arts teacher

 Department of Education
Schools Division of Capiz
SAN ANTONIO NATIONAL HIGH SCHOOL
0

ACCEPTANCE OF FINISHED MINOR REPAIRS

Name of Project:
Source of Fund: MOOE
Program of Works:
Quantity Unit Description Unit Cost Total Cost
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
TOTAL -

Expenses:

Labor
Materials -

Total -

Note:

Verified, inspected and found correct as to

program of works and specifications:

ANALEA E. FUENTES 0 TAMMY B. ESTORQUE

Chairman member 1 member 2
Inspection Committee Industrial Arts Teacher Property Custodian
 Department of Education
Region VI - Western Visayas
Division of Capiz
SAN ANTONIO NATIONAL HIGH SCHOOL
District of

CONSUMPTION REPORT FOR GASOLINE

MOOE

Received the material/s as indicated hereunder for grass cutting of school ground with an
estimated area of square meters.

QTY. UNIT ARTICLES U/P AMOUNT

TOTAL: -

Received by:

TAMMY B. ESTORQUE
School Property Custodian

Noted:

ANALEA E. FUENTES
School Head
 APPENDIX A

ITINERARY OF TRAVEL
Name:
Official Station:
Purpose of Travel:

Date Place to Visit Departure

Total
(2) (1) I HEREBY CERTIFY THAT I have reviewed the
foregoing itinerary, (2) the travel is necessary to the service,
(3) the period covered is reasonable, (4) the expenses claimed
are proper.

Atty. Benjie B. Doce, CPA, MBA

Supervisor/Immediate Supervisor

APPENDIX B
DECS, DIVISION OF CAPIZ
ROEL F. BERMEJO, CESO V
Agency Head

I hereby certify that I have completed the travel authorized in the Itinerary o
under the conditions indicated below.
Strictly in accordance with the prepa
Cut short explained below. Excess p
was refunded under O.R. No. _____
Extended as explained below. Addit
Other deviations as explained below

Attached supporting documents:

On Evidence and information of which I have knowledge, the travel w

Nicasio S. Frio
Acting Assistant Schools Division Superintandent

immediate supervisor
or head of office
 APPENDIX A
No.
Date:
ITINERARY OF TRAVEL
Position:
Monthly Salary:

Means of
Arrival Transportation Fare Per Diems Total
-
-
-
-
-
-
-
-
-
-
-
-
eviewed the (1) Prepared by:
ary to the service,
e expenses claimed Darwin Brillo name of the person
who travelled
ADAS III
(2) Approved by:

Nicasio S. Frio
Acting Assistant Schools Division Superintandent

APPENDIX B
Date:
Station:

the travel authorized in the Itinerary of Travel No. _______ dated ______________

trictly in accordance with the prepared itinerary.

ut short explained below. Excess payment in the amount of ________________
as refunded under O.R. No. _________________ dated ____________________
xtended as explained below. Additional itinerary was submitted.
ther deviations as explained below:

.
hich I have knowledge, the travel was undertaken.

Respectfully submitted:

Darwin Brillo
ADAS III name of the person
who travelled
 ANNEX A

Department of Education
Region VI - Western Visayas
SAN ANTONIO NATIONAL HIGH SCHOOL

CERTIFICATION OF EXPENSES NOT REQUIRING RECEIPTS

Pursuant to COA Circular No. 2017-001- dated June 19, 2017
Employee
Name of Employee
No.
Office
Division
Particulars Amount ((₱)

TOTAL -
Purpose

I hereby certify that the above expenses are incurred as they are necessary for the above cited purpose that above goods
and services were acquired from parties not issuing receipts. And that I am fully aware that wilful falsification of statements is
punishable by law.
Certified Correct: Noted By:
Signature:
Printed Name:
Employee Immediate Supervisor
Date Date

DS FO
SCHOO
SCHOOL HEAD OR
TEACHER
DS FOR SCHOOL HEAD
SCHOOL HEAD FOR TEACHER
 Republic of the Philippines
DEPARTMENT OF EDUCATION
SAN ANTONIO NATIONAL HIGH SCHOOL

ICT Equipment Diagnostic Report

Requested By: Date:

Classroom/ Office:

School:

Equipment Name:

Inventory No: Serial No.:

Problem (describe fully):

Property Custodian Approval: Date:

Repair/ Diagnostics Completed By:

Diagnosis:

Results/ Options:

Approximate Cost:

School Head Approval: Date:

TAMMY B. ESTORQUE ANALEA E. FUENTES

Property Custodian School Head