Appendix 34

CHECKS AND ADVICES TO DEBIT ACCOUNT DISBURSEMENTS RECORD

Entity Name : _________________________________________ Fund Cluster :_________________

Bank Name/Bank Account Number : _____________________ Sheet No. : ____________________

________________________________________________ ___________________________ _______________________

Accountable Officer Official Designation Station
NCA/DS/DV/Payroll Check/ADA Amount
Nature
Serial No. UACS Object NCA
Payee of
Date Code Received/ Check ADA NCA/Bank
No. Date Date
Released
Payment
Deposit Issued Issued Balance
Check ADA Made

CERTIFICATION

I hereby certify on my official oath that the foregoing is a correct and complete record of all checks/ADAs issued by me in my capacity as _________________________ of
_____________________________________
(Designation) (Name of Agency)
during the period from _______________ to _______________, inclusive, as indicated in the corresponding columns.

___________________________
Name and Signature
________________
Date

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