Report of Disbursements Form
2
REPORT OF DISBURSEMENTS Agency Period Covered: Date DV/Payroll esponsibility Payee No. Center Code CERTIFICATION I hereby certify that this Report of Disbursements in _____ sheets is a ful and correct statement of the disbursements made by me and that this is in liquidation per Check No. _____________ dated ______________. Disbursing Officer of the cash advance granted last ___________ in the amount of P _______________ Report No.:_________ Sheet No.: _________ Date Nature of Payment Amount 125 AO 6/15/02
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Report of Disbursements Form
Transcript of Report of Disbursements Form
REPORT OF DISBURSEMENTS
Agency Period Covered:
DateDV/Payroll Responsibility
PayeeNo. Center Code
CERTIFICATION I hereby certify that this Report of Disbursements in _____ sheets is a full, true and correct statement of the disbursements made by me and that this is in liquidation
per Check No. _____________ dated ______________.
Disbursing Officer
of the cash advance granted last ___________ in the amount of P_______________
Report No.:_________Sheet No.: _________
Appendix 56
Date
Nature of Payment Amount
125A
O 6/15/02