Sheet1 A. ACCOUNTABILITY FOR ACCOUNTABLE FORMSName of form and NumberBeginning BalanceRECEIPTISSUEDENDING BALANCEInclusive Serial NumbersQTYFROMTOQTYFROMTOQTYFROMTOQTYFROMTOAF3 514505876301587675058763015876342587634558763665876368587638558763875876398587640258764045876434

B. SUMMARY OF COLLECTIONS AND REMITTANCES/DEPOSITS

Beginning BalanceAdd: CollectionsTotal13,960.00Less: Remittances/DepositsBalance

CERTIFICATIONVERIFICATION AND ACKNOWLEDGEMENT I HEREBY CERTIFY that the foregoing report of Collections and Deposits and Accountability for accountable Forms is true and Correct I HEREBY CERTIFY that the foregoing report of Collections has been Verified and Acknowleged receipt: ____________________________

JIMMY A. DERADAZENAIDA M. CALUBAQUIBCashier DesignateCollecting Officer A. ACCOUNTABILITY FOR ACCOUNTABLE FORMSName of form and NumberBeginning BalanceRECEIPTISSUEDENDING BALANCEInclusive Serial NumbersQTYFROMTOQTYFROMTOQTYFROMTOQTYFROMTO

B. SUMMARY OF COLLECTIONS AND REMITTANCES/DEPOSITS

Beginning BalanceAdd: CollectionsTotalLess: Remittances/DepositsBalance

CERTIFICATIONVERIFICATION AND ACKNOWLEDGEMENT I HEREBY CERTIFY that the foregoing report of Collections and Deposits and Accountability for accountable Forms is true and Correct I HEREBY CERTIFY that the foregoing report of Collections has been Verified and Acknowleged receipt: ____________________________

JIMMY A. DERADAZENAIDA M. CALUBAQUIBCashier DesignateCollecting Officer

Sheet2

Sheet3