OBLIGATION REQUEST AND STATUS Serial No.

_____________
Date: ________________
Fund Cluster: __________

Payee

Office

Address

Responsibility UACS Object

Center
Particulars MFO/PAP Amount
Code

For the reimbursement

of one (1) Printer-
EPSON L5190
MULTIFUNCTION
PRINTER in the
amount of _______

P 13,700

TOTAL
P
Certified: Charges to appropriation/allotment Certified: Allotment available
A
necessary, B
and
. Lawful and under my direct supervision; and .. obligated for the
supporting purpose/adjustment necessary as
Documents valid, proper and legal Indicated above.

Signature: Signature:

Printed Name: Printed Name:

Position: Position: Chief, Budget Division

Head,Requesting Office/Authorized Representative Head Requesting Office/ Authorized
Representative

Date: Date:

C STATUS OF OBLIGATION
Reference Amount
Date Particular ORS/JEV/RCI/ Obligati Payabl Payment Balance
s RADAI No. on e Not Yet Due
Due and
(a) (b) (c) (a-b) (b-c)

TOTAL