Annex A

Republic of the Phiippines

PROVINCE OF ____________
Municipality of _______________
OBLIGATION REQUEST No.
Payee (JUAN DELA CRUZ)
Office
Address
Responsibility Particulars F.P.A. Account Amount
Center Code

Payroll for ________________________ _______________

Total P ____________
A. Certified B. Certified

Charges to appropriation/allotment necessary. Existence of available appropriation

Lawful and under my direct supervision
Supporting documents valid, proper and legal

Signature Signature
_______________________________
Printed Name Printed Name
Municipal Budget Officer
Position Position
Head, Requesting Office/Authorized Representative Head, Budget Unit/Authorized representative

Date Date