PURCHASE REQUEST

Barangay : CAMBASI P.R. No. : 2017-010-049

Municipality : MASANTOL Date : OCTOBER 18,2017
REQUISITION
Item Unit of Estimated Estimated
Qty. Item Description
No. Measure Unit Cost Amount
1 89 M3 BACKFILL MATERIALS 350.00 31,150.00

TOTAL ESTIMATED AMOUNT Php 350.00 Php 31,150.00

Purpose : FOR EMBANKMENT OF ELEMENTARY SCHOOL PLAYGROUND

Requested by: Approved by:

HON. JUAN Y. MENDOZA HON. CARLITO S. VIRAY

Signature Over Printed Name Signature Over Printed Name
Requisitioner Punong Barangay

10/18/2017 10/18/2017
Date Date
 CANVASS FORM
Supplier : P.R. No. :
Address : Date :

The following are our quotation for Barangay Cambasi, Masantol, Pampanga:
Item Unit of Total
Qty. Item Description Unit Cost
No. Measure Amount

TOTAL ESTIMATED AMOUNT Php - Php -

Quoted by: Canvassed by:

HON. REINER M. DUNGO

Signature Over Printed Name Signature Over Printed Name
Supplier/Representative SK Chairperson

Date Date
 PURCHASE ORDER
Barangay : Municipality :
Telephone No. : Province :

Supplier : P.O. No. :

Address : Date :
TIN : Mode :

Gentlemen:

Please deliver to this Office the following articles subject to the terms and conditions contained herein:

Place of Delivery : Delivery Term :

Date of Delivery : Payment Term :

Unit Particular Quantity Unit Cost Amount

TOTAL AMOUNT

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

Very truly yours,

Signature over Printed Name

Punong Barangay

Date

Conforme: Existence of available appropriation:

Signature over Printed Name Signature over Printed Name

Supplier Chairman, Committee on Appropriations

Date Date
 INSPECTION AND ACCEPTANCE REPORT
Barangay : Municipality : Masantol
Telephone No. : Province : Pampanga

Supplier : IAR No. :

Address : Date :
P.O. No. Invoice No.
Date : Date :

Unit Description Quantity Unit Cost Amount

TOTAL
INSPECTION ACCEPTANCE

x Inspected and verified as to quantity and x Complete

specifications
Partial (Pls. specify quantity received)

Signature over Printed Name Signature over Printed Name

Authorized Inspector Barangay Treasurer

Date Date
 PROPERTY ACKNOWLEDGMENT RECEIPT
Barangay : SAN ISIDRO ANAC Municipality : Masantol
Telephone No. : Province : Pampanga
Supplier : SILICON VALLEY PAR No. :
Address : 133 SM CITY PAMP. SAN FERNANDO Date :
P.O. No. 100-2014-09-249 Invoice No. 107151
Date : 9/22/2014 Date : 10/8/2014

Unit Particular Quantity Unit Cost Amount

Unit Epson L210 (Printer, Scanner, Copier) 1 7,795.00 7,795.00

Continuus Ink Tank System
Consumables: T664100 (Black)
T664200 (Cyan)
T6642300 (Magenta)
T6642400 (Yellow)

TOTAL AMOUNT Php 7,795.00 Php 7,795.00

RECEIVED BY ISSUED BY

ERNESTO S. YUMUL ARIEL M. BUSTOS

Signature over Printed Name Signature over Printed Name
Recipient/End-user Barangay Treasurer

10/10/2014 10/10/2014
Date Date
 INVENTORY CUSTODIAN SLIP
Barangay : Municipality : Masantol
Telephone No. : Province : Pampanga
Supplier : ICS No. :
Address : Date :
P.O. No. Invoice No.
Date : Date :

Unit Particular Quantity Unit Cost Amount

TOTAL AMOUNT
RECEIVED BY ISSUED BY

Signature over Printed Name Signature over Printed Name

Authorized Inspector Barangay Treasurer

Date Date
 LR No. :
LIQUIDATION REPORT Date :
Barangay : Municipality : Masantol
Telephone No. : Province : Pampanga

Accountable Offr. : Employee No.:

Address : Fund :
TIN : Type :

PARTICULARS AMOUNT

Total amount spent

Amount of Cash advance per DV. No. dated

Amount refunded per A.F. 51/OR No. dated

Amount to be reimbursed
A B C
Certified: Certified: Certified:
Existence of appropriations for Purpose of travel/cash advanced Supporting documents
the charges/expenses indicated duly accomplished complete
above Approved for payment:

Signature over Printed Name Signature over Printed Name Signature over Printed Name
Barangay Treasurer Punong Barangay Barangay Bookkeeper

Date Date Date

 MUNICIPALITY OF MASANTOL
Masantol, Pampanga
BARANGAY
REPORT FO COLLECTION AND DEPOSIT

Fund : Report No. : 201 - -

Accountable Officer : Date :

A. COLLECTIONS
1. For Collectors

Official Receipt/Serial No.

TYPE (FORM No.) Amount
From To
Php

TOTAL Php

2. For Liquidatin Officers/Treasurers

Name of Accountable Officer Report Amount

Php

TOTAL Php

B. DEPOSIT

Name of Accountable Officer Report Amount

Php

TOTAL Php
 MUNICIPALITY OF MASANTOL
Masantol, Pampanga
BARANGAY
REPORT FO COLLECTION AND DEPOSIT

Fund : Report No. : 201 - -

Accountable Officer : Date :

C. ACCOUNTABILITY FOR ACCOUNTABLE FORMS

Beginning Balance Receipt Issued Ending Balance

Name of Form and Number Inclusive SN Inclusive SN Inclusive SN Inclusive SN
Qty Qty Qty Qty
Form To Form To Form To Form To

D. SUMMARY OF COLLECTIONS AND DEPOSIT

Beginning Balance, LIST OF CHECKS:

Add : Collections Check No. Payor Amount
Cash
Check

Total
Less : Deposits
Ending Balance,
Total

CERTIFICATION VERIFICATION AND ACKNOWLEDGEMENT:

I hereby acknowledge receipt of the certified

I hereby certify that foregoing is the
complete and correct record of all my
collections as of this date. The remittances of
Php _____________________ are hereto
attached.
RCD complete with the deposits of
____________________________________
____________________________________
____________________________________
___ (Php
______________________________).

Barangay Treasurer Date Barangay Treasurer Date

 REPUBLIC OF THE PHILIPPINES

No.
(Office)
APPENDIX A

ITINERARY OF TRAVEL

Name Monthly Salary

Position
Official Station
Purpose of Travel

Place to be TIME Means of Trans- ALLOWABLE EXPENSES Total

Date
Visited Departure Arrival portation Transportation Per Diems Daily Allowances Amount

TOTAL

(1) Prepared By:

(2) I certfy that (1) I have reviewed the for going itinerary. (2) The
travel I necessary to the service. (3) The period covered is
reasonable. (4) The expenses claimed are proper.
(Official or Employee)

(3) APPROVED:

Supervisor

(Chief of Office)
 REPUBLIC OF THE PHILIPPINES

(Office)
APPENDIX B

CERTIFICATE OF TRAVEL COMPLETED

(Agency Head) Station

I certify that I have completed the travel authorized in itenerary of Travel No.
dated under conditions indicated below:

Strictly in accordance with the approved itinerary.

Cut short as explained below. Excess payment in the amount of Php was
Refunded on O.R No. dated

Extended as explained below. Additional itinerary was submitted.

Other deviation as explained below.

Explanations or justifications:

Evidence of travel attached hereto:

Respectfully Submitted:

(Officer or Employee)

On evidence and information of which I have knowledge, the travel was actually undertaken.

(Supervisor)
 Barangay _____________
City/Municipality of Masantol
Province of Pampanga

TRANSMITTAL LETTER (TL)

Date : ______________
To : The City/Municipal Accountant
City/Municipality of Masantol, Pampanga

Sir/Madam;

We submit herewith the original copies of the disbursement vouchers issued for the month of ( ____________,______) duly
acknowledged by the payees together with the supporting documents, and copies of the corresponding checks and Punong
Barangay's Certification (PBC).

DV CHECK PBC/s Issued

Payee Amount
Date No. Date No. Date No.

Please acknowledge reciept hereof.

Very truly your,

Barangay Treasurer
_______________________
Date

Noted by: Received By:

 Punong Barangay

Copy Furnished:

COA SA/ATL
 Summary of Cash Payment
For the period ___________________

Barangay: _________________________ City/Municipality: Masantol SCP No.: 201__ -____ - ____

Barangay Treasurer: ______________________ Province: Pampanga

Withholding
Payroll/ Gross
Date Payee Particulars Tax Net Amount
DV No. Amount Tax

TOTAL

Certification: Acknowledgment:
 I hereby certify that the foregoing is the complete and I hereby acknowledge the receipt of the certified SCP
correct records of all cash payments for the period _________ complete with the originals of the paid DVs/payroll and
to __________, 20____. The originals of all paid DVs/payrolls supporting documents.
are hereto attached.

____________________________________ _____________________________
Barangay Treasurer Barangay _______________
 DAILY TIME RECORD DAILY TIME RECORD DAILY TIME RECORD

(Name) (Name) (Name)

For the Month of For the Month of For the Month of

Official hours for arrival ( Regular days Official hours for arrival ( Regular days Official hours for arrival ( Regular days
and departure ( Saturdays and departure ( Saturdays and departure ( Saturdays

A.M. P.M. UNDERTIME A.M. P.M. UNDERTIME A.M. P.M. UNDERTIME

Day Day Day
Depar- Depar- Min- Depar- Depar- Min- Depar- Depar- Min-
Arrival Arrival Hours Arrival Arrival Hours Arrival Arrival Hours
ture ture utes ture ture utes ture ture utes
1 1 1
2 2 2
3 3 3
4 4 4
5 5 5
6 6 6
7 7 7
8 8 8
9 9 9
10 10 10
11 11 11
12 12 12
13 13 13
14 14 14
15 15 15
16 16 16
17 17 17
18 18 18
19 19 19
20 20 20
21 21 21
22 22 22
23 23 23
24 24 24
25 25 25
26 26 26
27 27 27
28 28 28
29 29 29
30 30 30
31 31 31
TOTAL ---------------------------------------------- TOTAL ---------------------------------------------- TOTAL ----------------------------------------------
I CERTIFY on my honor that the above is a true and correctreport of the I CERTIFY on my honor that the above is a true and correctreport of the I CERTIFY on my honor that the above is a true and correctreport of the
hours of work performed, record of which wasmade daily at the time of hours of work performed, record of which wasmade daily at the time of hours of work performed, record of which wasmade daily at the time of
arrival at and departure from office. arrival at and departure from office. arrival at and departure from office.

_____________________________________ _____________________________________ _____________________________________

( Employee's Signature ) ( Employee's Signature ) ( Employee's Signature )

Verified as to the prescribed office hour: Verified as to the prescribed office hour: Verified as to the prescribed office hour:

In Charge In Charge In Charge

 SUBSIDIARY LEDGER
__________________________________
LGU

Fund

Nature of Account Account Code

Office/Address GL
Contact Person/Number SL

Amount
Date Particulars Ref.
Debit Credit Balance
 GENERAL LEDGER
_____________________________
LGU

Fund :
Account Title : Account Code :

Amount
Date Particulars Ref.
Debit Credit Balance
 D.V. No. : 2016- -
DISBURSEMENT VOUCHER
Date :

Barangay : Municipality : MASANTOL

Telephone No. : Province : PAMPANGA

Payee : Employee No.:

Address : Fund :

TIN : Type :

PARTICULARS AMOUNT

Php

AMOUNT IN WORDS:

TOTAL AMOUNT Php

A B C
Certified by: Certified: Certified:
Existence of appropriaitions Funds (Cash) Available: As to validity, propriety
for the
charges/expenses indicated legality
and legality
of claim
of claim
above Approved for Payment;

Signature over Printed Name Signature over Printed Name Signature over Printed Name
Chairman, CCA Barangay Treasurer Punong Barangay

Date Date Date

D
Received Payment:
Bank Name LANDBANK Apalit, Pampanga

Check No.
Signature over Printed Name/Supplier
Date

Date OR Number Date :

 Republic of the Philippines
Province of Pampanga
MUNICIPALITY OF MASANTOL
Barangay ________________

Date

TO WHOM IT MAY CONCERN:

This is to cerfity that the employment of the following laborers llisted hereunder is/are hereby approved
pursuant to the Provisions of BPW Circular No. To wit:

PERIOD OF EMPLOYMENT
NAMES DESIGNATION RATE PER DAY
FROM TO

REMARKS:

1. To be employed from time to time depending upon the extingency of works and availability of
funds
2. It is understood the that employement of the laborers concerned will ceased automatically at
the end of the period of employment
3. The Provisions of BPW Circular No. 5 dated May 14, 1952 and its supplement have been
complied with.

Punong Barangay
 MUNICIPALITY OF MASANTOL
MASANTOL, PAMPANGA
LABOR PAYROLL
BARANGAY __________________

Project ________________________ Date:

No. NAME POSITION PERIOD COVERED No. OF DAYS RATE PER DAY AMOUNT PAID SIGNATURE NUMBER

10

11

12

13

14

15

TOTAL -

Certified Correct: Approved by: Received from

Barangay Treasurer Punong Barangay Barangay T

ALITY OF MASANTOL
ANTOL, PAMPANGA
ABOR PAYROLL
GAY __________________

DATE PLACE OF ISSUE

Barangay Treasurer
 TURN OVER OF MONEY AND PROPERTY ACCOUNTABILITIES
Barangay City/Municipality : MASANTOL
Tel. No. Province : PAMPANGA

A. Money
Cash

No. Of Pieces Denomination Amount

Checks
Drawee Bank Number Date Amount

TOTAL
B. Accountable Forms
Inclusive Serial Nos.
Quantity Name of Forms
From to

C. Property, Plants & Equipment

Quantity Unit Description Property No.

D. Documents / Forms
Quantity Unit Description

Transferred by: Received by:

I hereby CERTIFY that the above listed item were transferred I hereby CERTIFY that we received from _______________
to incoming Barangay captain _____________________________ the above listed item.
(Outgoing/Name of Accountable Officer)

___________________________
Name, Designation and Signature Barangay Treasurer
of the Outgoing Accountable Officer
 ______________ _____________
Date Date

___________________________
Outgoing Barangay Captain Incoming Barangay Captain

Witnessed by:
______________________________
DILG Representative COA Representative
I hereby CERTIFY that we received from _______________
 REPORT ON THE PHYSICAL COUNT OF PROPERTY, PLANT AND EQUIPMENT
As of , 201
Barangay : City/Municipality : Masanto
Tel. No. : Province :
For which is accountable
(Name of Accountable Officer) (Offical Designation
PROPERTY UNIT OF BALANCE PER ON HAND PER
SHORTAGE/OVERAGE
ARTICLE DESCRIPTION NUMBER MEASURE UNIT VALUE CARD (Quantity) COUNT
(QUANTITY) Quantity Value
1 2 3 4 5 6 7 8

A B C
Prepared by : (Item 1 to 6) Certified Correct by : (Items 7 to 9) Approved by :

___________________________ ____________________________ _________________

Signature over Printed Name Signature over Printed Name Signature over Pri
Barangay Record Keepper Head, Inventory Committee Punong Bara

Date Date Date

T OF PROPERTY, PLANT AND EQUIPMENT
, 201
City/Municipality : Masantol
Province : Pampanga

REMARKS

___________________________
Signature over Printed Name
Punong Barangay

Date
General Form No. 02
Revised January 1992
REIMBURSMENT EXPENSE RECIEPT
Date No.
RECEIVED From _____________________________________________________
(Name)
____________________________________________________________ the amount
of ____________________________________________________ (P _____________)
(In Words) (In Figures)
in payment for _________________________________________________________
(Payments for sursistence, services,
_________________________________________________________________________
rental of transportation should sho inclusive dates,
_________________________________________________________________________
purpose, distance, inclusive points of travel, etc.)
________________________________________________________________________
________________________________________________________________________
PAYEE
Name/Signature ________________________________________________________
Address _______________________________________________________________
Comm. Tax Cert. No. _____________________________________________________
Date of Issue ___________________________________________________________
Place of Issue __________________________________________________________
________________________________________________________________________
________________________________________________________________________
WITNESS
Name/Signature ________________________________________________________
Address _______________________________________________________________
Comm. Tax Cert. No. _____________________________________________________
Date of Issue ___________________________________________________________
Place of Issue __________________________________________________________
General Form No. 02
Revised January 1992
REIMBURSMENT EXPENSE RECIEPT
Date No.
RECEIVED From _____________________________________________________
(Name)
____________________________________________________________ the amount
of ____________________________________________________ (P _____________)
(In Words) (In Figures)
in payment for _________________________________________________________
(Payments for sursistence, services,
_________________________________________________________________________
rental of transportation should sho inclusive dates,
_________________________________________________________________________
purpose, distance, inclusive points of travel, etc.)
________________________________________________________________________
________________________________________________________________________
PAYEE
Name/Signature ________________________________________________________
Address _______________________________________________________________
Comm. Tax Cert. No. _____________________________________________________
Date of Issue ___________________________________________________________
Place of Issue __________________________________________________________
________________________________________________________________________
________________________________________________________________________
WITNESS
Name/Signature ________________________________________________________
Address _______________________________________________________________
Comm. Tax Cert. No. _____________________________________________________
Date of Issue ___________________________________________________________
Place of Issue __________________________________________________________
 PROGRAM OF WORK
Barangay ______________________

DETAILED ESTIMATE
POW No. : Date:
Name of Project
Item of Works

Item No. Quantity in sq.m Length in m. Width in m. Thickness in m.

I. Materials
Description Unit Quantity Unit Cost Amount

Total Materials Cost Php

II. Labor
Position No. Days Rate/day Amount

Total Labor Cost Php

III. Equipment
Type No. Days Rate/day Amount

Total Equipment Cost Php

 Total Direct Cost Php

Prepared by: Approved by:

__________________________________ ______________________________
Committe on Public Works Barangay Captain
 SUMMARY FOR REIMBURSEMENT
Barangay ____________________
FOR THE PERIOD _______________ TO _______________ 2014

DATE O. R. NO. PARTICULARS CODE AMOUNT

1 Php
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
Php

CERTIFIED BY: APPROVED BY:

____________________________ _________________________________
Barangay Treasurer Punong Barangay
 BARANGAY _________________________
MUNICIPALITY OF MASANTOL
Masantol, Pampanga

FUEL CONSUMPTION REPORT

For the period ________________________
(Php)

FCR NO. ____________________

DATE INVOICE NO. PLATE NO. QTY. IN LITER/S UNIT COST TOTAL COST

GRAND TOTAL

NOTE BENE: VEHICLE TRIP TICKETS CORRESPONDING TO EACH INVOICE ARE AVALILABLE ON FILE

Prepared by: Certified Correct Approved by:

________________________________ ______________________________ _____________________________

Driver Barangay Treasurer Punong Barangay
Municipality of Masantol P.O. No.
Barangay Date :

PURCHASE ORDER

Name of Owner
Manager
Addres

Please furnish our government owned vehicle the following gas, oil & lubricants

Type fo Vehicle Plate No.

No. Unit Description Qty. Unit Cost Total

Conforme

_______________________ _______________________ ______________________

Manager Brgy. Treasurer Punong Brgy.

Municipality of Masantol PO No.

Barangay Date :

PURCHASE ORDER

Name of Owner
Manager
Addres

Please furnish our government owned vehicle the following gas, oil & lubricants

Type fo Vehicle Plate No.

No. Unit Description Qty. Unit Cost Total

Conforme

_______________________ _______________________ ______________________

Manager Brgy. Treasurer Punong Brgy.
 REPUBLIC OF THE PHILIPPINES
PROVINCE OF PAMPANGA
MUNICIPALITY OF MASANTOL

REPORT OF GASOLINE USED FOR PUNONG BARANGAY

COVERED PERIOD FROM ___________________

PAYEE :
ADDRESS :

DATE PLATE NO. FROM ROUTE OF DESTINATION AMOUNT

TOTAL Php -

Prepared by: Approved by:

____________________________ ________________________________
Barangay Treasurer Barangay Chairman
 CERTIFICATE OF PRE-INSPECTION
OF MOTOR VEHICLES

This is to certify the we have made a pre-inspection pertaining to barangay vehicle with
a Plate No. ______________ from which the following observation and findings occured.

ESTIMATED
ITEM CONDITION QTY.
U/COST TOTAL COST
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
TOTAL Php

Located at _____________________________ Masantol, Pampanga on the ______ day of

_________________, 20 ___.
We cerfity further that the abovementioned vehicle requires and maintenance with an
estimated cost of Php _____________ as stated above.
Issued this _______ day of ___________ 20____.

Inspected by:

________________________________
Designated Mechanic

Approved by:

________________________________
Barangay Chairman
 ACCEPTANCE AND FINAL INSPECTION REPORT
FOR MOTOR VEHICLES

Description of Item

Location

Contract Amount

Contract/Supplier

TO WHOM IT MAY CONCERN:

This is to certify that we have conducted a joint inspection of the above stated Office/IT

Equipment and the same wa accomplished _____% on the ______ day of ____________________ 20___.

in accordance the approved contract, program of work, plans and specifications; found the same

to be satisfactory and physically completed and therfore recommended for payment.

Issued this ______ day of ____________________ 20_____.

Inspected by:

________________________________

Designated Mechanic

Approved by:

________________________________

Barangay Chairman
 REPUBLIC OF THE PHILIPPINES
PROVINCE OF PAMPANGA
MUNICIPALITY OF MASANTOL
BARANGAY ___________________
LIST OF BONDED BARANGAY OFFICIALS

EFFECTIVITY DATE
NAME OF PUBLIC OFFICER DESIGNATION/BARANGAY RISK No. AMOUNT BOND PREMIUM REMAKS
FROM TO

TOTAL - -

Prepared by: Certified and Approved by:

_____________________________
Signature Over Printed Name Name & Designation of Authorized Official
Barangay Treasurer Barangay Chairman
 MUNICIPALITY OF MASANTOL
MASANTOL, PAMPANGA
SCHOLARSHIP
BARANGAY __________________

for the year _______

Date: _____________

No. NAME OR NUMBER AMOUNT SIGNATURE

10

11

12

13

14

15

16

17

18

19

20

TOTAL

Certified Correct: Approved By:

_______________________ _________________________
Barangay Treasurer Punong Barangay
 WASTE MATERIALS REPORT
Municipality : Office :
Telephone No. : Province :
Supplier : WMR No. :
Address : Date :
Place of Storage : Invoice No.
Address : Date :

ITEMS FOR DISPOSAL

RECORD OF SALES
ITEM UNIT DESCRIPTION QUANTITY
O.R. NO. AMOUNT

A B
Certified Correct: Approved by:

Signature over Printed Name Signature over Printed Name

Municipal Treasurer Municipal Mayor

CERTIFICATE OF INSPECTION
I hereby certify that the property enumerated above were disposed of as follows:

Item ALL Destroyed

Item Sold at private sale
Item Sold at auction
Item Transferred without cost to

C D
Property Inspector Witness to Disposition:

Signature over Printed Name Signature over Printed Name

Inspection Officer