Account Title Account Code Debit

Electricity Expenses 50204020 5,004

1 Telephone Expenses 50205020 1,907
Cash in Bank-Local Currency, Savings Account-LBP 10104040
To record payment of bills from utility companies.

Water Expenses 50204010 600.56

2 Cash-MDS, Regular 10104040
To recordpayment for water expenses.

Furniture and Fixtures 10607010 19,500

3 Cash-MDS, Regular 10104040
To recognize purchase of furniture and fixtures.

Mobile 50205020 8,999

4 Cash-MDS, Regular 10104040
To record purchase of communication equipment.

Drugs and Medicine Expenses 50203070 2,219.50

5 Cash-MDS, Regular 10104040
To record cash payment for purchase of medicine.

Other Land Improvements 50213020 1,301

6 Cash-MDS, Regular 10104040
To record cash payment for purchase of paint.

Drugs and Medicine Expenses 50203070 806

7 Cash-MDS, Regular 10104040
To record payment for purchase of medicine.

Other Professional Services 50211990 650

8 Cash-MDS, Regular 10104040
To record cash payment for veterinary services.

Fuel, Oil and Lubricant Expenses 50203090 1,650

9 Cash-MDS, Regular 10104040
To record cash payment for fuel.

10 Food Supplies Expenses 50203050 657.75

Cash-MDS, Regular 10104040
To record payment for puchase of food supplies.

11 Drugs and Medicine Expenses 50203070 995.25

 Cash-MDS, Regular 10104040
To record payment for purchase of medicine.

12 Other Professional Services 50211990 450

Cash-MDS, Regular 10104040
To record cash payment for veterinary services.

13 Office Supplies Expenses 50203010 364.36

Cash-MDS, Regular 10104040
To record payment for purchased office supplies.

14 Fuel, Oil and Lubricant Expenses 50203090 500

Cash-MDS, Regular 10104040
To record cash payment for fuel.

15
Credit

6911

600.56

19,500

8,999

2,219.50

1,301

806

650

1,650

657.75
995.25

450

364.36

500
 D

Mode of Payment MDS Check

Payee

Address

Particulars

Amount Due
A. Certified: Expenses/Cash Advance necessary, lawful and incurred under my direct supervision.

B. Accounting Entry:
Account Title

C. Certified:
Cash available

Subject to Authority to Debit Account (when applicable)

Supporting Supporting documents complete and amount claimed

proper

Signature

Printed Name

Position
Head, Accounting Unit/Authorize
 Date

E. Receipt of Payment

Check/ ADA No. :

Signature :

Official Receipt No. & Date/Other Documents

 Entity Name

DISBURSEMENT VOUCHER

Commercial Check ADA

TIN/Employee No.:

Responsibility Center

ue
on.

________________________________________
Printed Name, Designation and Signature of Supervisor

unt Title UACS Code

D. ApproveApproved for Payment

Signature

Printed Name

Position
Head, Accounting Unit/Authorized Representative
 Date

Date : Bank Name & Account Number:

Date : Printed Name:

 Fund Cluster :

Date :
DV No. :

Others (Please specify)

_________________
oyee No.: ORS/BURS No.:

ponsibility Center MFO/PAP Amount

UACS Code Debit Credit

Approved for Payment

Signature

Printed Name

Position
Agency Head/Authorized Representative
 Date

JEV No.
e & Account Number:

me: Date
 Amount

Credit

ve
 OBLIGATION REQUEST AND STATUS
HSL AGENCY
Entity Name

Payee Cotabato Light

Office

Address

Responsibility Center Particulars MFO/PAP

MOOE - Electricity 103-00-1-00-00-00000

Total

A. B.
Certified: Charges to appropriation/alloment are Certified: Allotment availab
necessary, lawful and under my direct supervision;and for the purpose/adjustment n
supporting documents valid, proper and legal indicated above

Printed Name:
_________________
Signature :
_________________ ___________________________________ Signature :
__ ___________________________________ Printed Name:
Position : ___________________________________ Position :
Head, Requesting Office/Authorized Representative
Date : ___________________________________ Date :

C. STATUS OF OBLIGATION
Reference Amount

ORS/JEV/Check/ Obligation Payable

Date Particulars
ADA/TRA No.

(a) (b)
MOOE - Electricity ₱ 5,004.00
 Serial No. : 02-01101101-2021-03-000019 OBLIGATION REQUEST AN
Date : March 24, 2021 HSL AGENCY
Fund Cluster : Regular Agency Fund Entity Name

Payee PLDT

Office

Address
UACS
Object Amount Responsibility Center Particulars
Code
5-02-04-02 ₱ 5,004.00 MOOE - Internet Subs

₱ 5,004.00

A.
rtified: Allotment available and obligated Certified: Charges to appropriation/alloment
r the purpose/adjustment necessary as necessary, lawful and under my direct supervision;and
dicated above supporting documents valid, proper and legal

Printed Name:
_________________
______________________________ Signature :
_________________ ___________________________________
______________________________ __ ___________________________________
______________________________
Head, Budget Division/Unit/Authorized Position : ___________________________________
Representative Head, Requesting Office/Authorized Repres
____________________________ Date : ___________________________________

N C. ST
Amount Reference
Balance
Payment ORS/JEV/Check/
Not Yet Due Due and Demandable Date Particulars
ADA/TRA No

(c) (a-b) (b-c)

MOOE - Internet Subscription
 Serial No. : 02-01101101-2021-03-
ON REQUEST AND STATUS 00020
HSL AGENCY Date : March 17, 2021
Entity Name Fund Cluster : Regular Agency
Fund
Payee

Office

Address
UACS
Particulars MFO/PAP Object Amount Responsibility Ce
Code
MOOE - Internet Subscription 103-00-1-00-00-000005-02-05-03 ₱ 1,907.00

Total ₱ 1,907.00

B. A.
o appropriation/alloment are Certified: Allotment available and obligated
direct supervision;and for the purpose/adjustment necessary as
oper and legal indicated above

Printed Name:
_________________
___________________ Signature : ______________________________ Signature :
_________________
___________________ Printed Name: ______________________________ __
Head, Budget
___________________ Position : ______________________________
Division/Unit/Authorized Position :
Office/Authorized Representative Representative
___________________ Date : ____________________________ Date :

STATUS OF OBLIGATION C.
e Amount
Balance

ORS/JEV/Check/ Obligation Payable Payment Due and

Not Yet Due Date
ADA/TRA No. Demandable

(a) (b) (c) (a-b) (b-c)

₱ 1,907.00
 OBLIGATION REQUEST AND STATUS
HSL AGENCY
Entity Name

Payee Metro Cotabato Water District

Office

Address

Responsibility Center Particulars MFO/PAP

MOOE - Water Expenses 103-00-1-00-00-00000

Total

B.
Certified: Charges to appropriation/alloment are Certified: Allotment available and obli
necessary, lawful and under my direct supervision;and for the purpose/adjustment necessary as
supporting documents valid, proper and legal indicated above

Printed Name:
_________________
Signature :
_________________ ___________________________________ Signature :
__ ___________________________________ Printed Name:
Position : ___________________________________ Position :
Head, Requesting Office/Authorized Representative
Date : ___________________________________ Date :

STATUS OF OBLIGATION
Reference Amount

ORS/JEV/Check/ Obligation Payable

Particulars
ADA/TRA No.

(a) (b)
MOOE - Water Expenses ₱ 600.56
 Serial No. : 02-01101101-2021-01-000019
Date :April 12, 2021 HSL AGENC
Fund Cluster : Regular Agency Fund Entity Name

Payee Superama Hypermarket

Office

Address

UACS Object
Amount Responsibility Center Particula
Code
5-02-04-01000 ₱ 600.56 MOOE - Furniture a

₱ 600.56

A.
Certified: Allotment available and obligated Certified: Charges to appropriation/allom
for the purpose/adjustment necessary as necessary, lawful and under my direct supervision;an
indicated above supporting documents valid, proper and legal

Printed Name:
_________________
______________________________ Signature :
_________________ __________________________________
______________________________ __ __________________________________
______________________________
Head, Budget Division/Unit/Authorized Position : __________________________________
Representative Head, Requesting Office/Authorized Rep
____________________________ Date : __________________________________

ION C.
Amount Reference
Balance
Payment Due and
Not Yet Due Date Particulars
Demandable

(c) (a-b) (b-c)

MOOE - Furniture and Fixtures
 HSL AGENCY Date :June 19, 2021
Entity Name Fund Cluster : Regular Agency Fund

Superama Hypermarket

UACS Object
Particulars MFO/PAP Amount
Code
MOOE - Furniture and Fixtures 103-00-1-00-00-00000 5-02-04-020 ₱ 19,500.00

Total ₱ 19,500.00

B.
Charges to appropriation/alloment are Certified: Allotment available and obligated
d under my direct supervision;and for the purpose/adjustment necessary as
ts valid, proper and legal indicated above

___________________________ Signature : ______________________________

___________________________ Printed Name: ______________________________
___________________________ Position : ______________________________
Head, Budget Division/Unit/Authorized
equesting Office/Authorized Representative Representative
___________________________ Date : ____________________________

STATUS OF OBLIGATION
Reference Amount
Balance
Obligation Payable Payment Due and
ORS/JEV/Check/
Not Yet DueDemanda
ADA/TRA No.
ble
(a) (b) (c) (a-b) (b-c)
₱ 19,500.00
 HSL AGENCY
Entity Name

Payee DKT Phonetech World

Office

Address

Responsibility Center Particulars MFO/PAP

MOOE - Mobile 103-00-1-00-00-00000

Total

A. B.
Certified: Charges to appropriation/alloment are
necessary, lawful and under my direct supervision;and
supporting documents valid, proper and legal

Printed Name:
_________________
Signature :
_________________ ___________________________________ Signature :
__ ___________________________________ Printed Name:
Position : ___________________________________ Position :
Head, Requesting Office/Authorized Representative
Date : ___________________________________ Date :

C. STATUS OF OBLIGATION
Reference Amount

ORS/JEV/Check/ Obligation Payable

Date Particulars
ADA/TRA No.

(a) (b)
MOOE - Mobile ₱ 8,999.00
 Date :April 12, 2021 HSL AGENCY
Fund Cluster : Regular Entity Name
Agency Fund
Payee Mercury Drug - Cot City Rosary Heig

Office

Address
UACS
MFO/PAP Object Amount Responsibility Center Particulars
Code
103-00-1-00-00-000005-02-05-01 ₱ 8,999.00 MOOE - Drugs and Medicine Ex

₱ 8,999.00

A.
Certified: Allotment available and obligated Certified: Charges to appropriation/alloment are
for the purpose/adjustment necessary as necessary, lawful and under my direct supervision;and
indicated above supporting documents valid, proper and legal

Printed Name:
_________________
Signature : ______________________________ Signature :
_________________ ___________________________________
Printed Name: ______________________________ __ ___________________________________
Head, Budget
Position : ______________________________
Division/Unit/Authorized Position : ___________________________________
Representative Head, Requesting Office/Authorized Representati
Date : ____________________________ Date : ___________________________________

TION C. STATUS O
Amount Reference
Balance
Payable Payment Due and
ORS/JEV/Check/
Not Yet DueDemanda Date Particulars
ADA/TRA No.
ble
(b) (c) (a-b) (b-c)
MOOE - Drugs and Medicine Expenses
 HSL AGENCY Date :June 11, 2021
Entity Name Fund Cluster : Regular
Agency Fund
Drug - Cot City Rosary Heights Sinsuat Ave. Payee

Office

Address
UACS
Particulars MFO/PAP Object Amount Responsibility Center
Code
OOE - Drugs and Medicine Expenses 103-00-1-00-00-000005-02-03-07 ₱ 2,219.00

Total ₱ 2,219.00

B. A.
o appropriation/alloment are Certified: Allotment available and obligated
direct supervision;and for the purpose/adjustment necessary as
oper and legal indicated above

Printed Name:
_________________
___________________ Signature : ______________________________ Signature :
_________________
___________________ Printed Name: ______________________________ __
Head, Budget
___________________ Position : ______________________________
Division/Unit/Authorized Position :
Office/Authorized Representative Representative
___________________ Date : ____________________________ Date :

STATUS OF OBLIGATION C.
e Amount
Balance
Obligation Payable Payment Due and
ORS/JEV/Check/
Not Yet DueDemanda Date
ADA/TRA No.
ble
(a) (b) (c) (a-b) (b-c)
₱ 2,219.00
 HSL AGENCY Date :April 12, 2021
Entity Name Fund Cluster : Regular
Agency Fund
Payee CITIHARDWARE GENSAN INC.,

Office

Address
UACS
Responsibility Center Particulars MFO/PAP Object
Code
MOOE - Other Land Improvements 103-00-1-00-00-000005-02-13-02

Total

B.
Certified: Charges to appropriation/alloment are Certified: Allotment available and obli
necessary, lawful and under my direct supervision;and for the purpose/adjustment necessary as
supporting documents valid, proper and legal indicated above

Printed Name:
_________________
Signature :
_________________ ___________________________________ Signature : ________________________
__ ___________________________________ Printed Name: ________________________
Head, Budget
Position : ___________________________________ Position : ________________________
Division/Unit/Authorized
Head, Requesting Office/Authorized Representative Representative
Date : ___________________________________ Date : ________________________

STATUS OF OBLIGATION
Reference Amount

ORS/JEV/Check/ Obligation Payable Payment

Particulars
ADA/TRA No.

(a) (b) (c)

MOOE - Other Land Improvements ₱ 1,301.00
 Date :April 12, 2021 HSL AGENCY
Fund Cluster : Regular Entity Name
Agency Fund
Payee Mercury Drug - Cotabato City Plaza

Office

Address

Amount Responsibility Center Particulars

₱ 1,301.00 MOOE - Drugs and Medicine Expenses

₱ 1,301.00 Total

A.
: Allotment available and obligated Certified: Charges to appropriation/alloment are
urpose/adjustment necessary as necessary, lawful and under my direct supervision;and
supporting documents valid, proper and legal

Printed Name:
_________________
______________________________ Signature :
_________________ ___________________________________
______________________________ __ ___________________________________
Head, Budget
______________________________
Division/Unit/Authorized Position : ___________________________________
Representative Head, Requesting Office/Authorized Representative
____________________________ Date : ___________________________________

C. STATUS OF OBLIGATION
ount Reference
Balance
Due and
ORS/JEV/Check/
Not Yet DueDemanda Date Particulars
ADA/TRA No.
ble
(a-b) (b-c)
MOOE - Drugs and Medicine Expenses
 Date :June 11, 2021 HSL
Fund Cluster : Regular En
Agency Fund
y Plaza Payee

Office

Address
UACS
rs MFO/PAP Object Amount Responsibility Center
Code
dicine Expenses 103-00-1-00-00-000005-02-03-07 ₱ 806.00

Total ₱ 806.00

B. A.
ent are Certified: Allotment available and obligated Certified:
d for the purpose/adjustment necessary as necessary, lawful and under my direct su
indicated above supporting documents valid, proper and

Printed Name:
_________________
_ Signature : ______________________________ Signature :
_________________ ________________________
_ Printed Name: ______________________________ __ ________________________
Head, Budget
_ Position : ______________________________
Division/Unit/Authorized Position : ________________________
Representative Head, Requesting Office/Au
_ Date : ____________________________ Date : ________________________

ATUS OF OBLIGATION C.
Amount Reference
Balance
Obligation Payable Payment Due and
Not Yet DueDemanda Date Particulars
ble
(a) (b) (c) (a-b) (b-c)
₱ 806.00 MOOE - Other Professional Services
 HSL AGENCY Date :June 11, 2021
Entity Name Fund Cluster : Regular
Agency Fund
ANIMAL CLINIC

UACS
Particulars MFO/PAP Object Amount
Code
MOOE - Other Professional Services 103-00-1-00-00-000005-02-11-99 ₱ 650.00

Total ₱ 650.00

B.
Charges to appropriation/alloment are Certified: Allotment available and obligated
, lawful and under my direct supervision;and for the purpose/adjustment necessary as
g documents valid, proper and legal indicated above

___________________________________ Signature : ______________________________

___________________________________ Printed Name: ______________________________
Head, Budget
___________________________________ Position : ______________________________
Division/Unit/Authorized
Head, Requesting Office/Authorized Representative Representative
___________________________________ Date : ____________________________

STATUS OF OBLIGATION
Reference Amount
Balance
Obligation Payable Payment Due and
ORS/JEV/Check/
Particulars Not Yet DueDemanda
ADA/TRA No.
ble
(a) (b) (c) (a-b) (b-c)
her Professional Services ₱ 650.00
 HSL AGENCY
Entity Name

Payee BANGSAMORO OIL AND FUELS CORPORATION

Office

Address

Responsibility Center Particulars MFO/PAP

MOOE - Fuel, Oil and Lubricant Expenses 103-00-1-00-00-00000

Total

A. B.
and obligated Certified: Charges to appropriation/alloment are
necessary, lawful and under my direct supervision;and
supporting documents valid, proper and legal

Printed Name:
_________________
______________ Signature :
_________________ ___________________________________ Signature :
______________ __ ___________________________________ Printed Name:
______________ Position : ___________________________________ Position :
Head, Requesting Office/Authorized Representative
____________ Date : ___________________________________ Date :

C. STATUS OF OBLIGATION
Reference Amount

ORS/JEV/Check/ Obligation Payable

Date Particulars
ADA/TRA No.

(a) (b)
MOOE - Fuel, Oil and Lubricant Expenses ₱ 1,650.00
 Date :June 11, 2021 HSL AGENCY
Fund Cluster : Regular Entity Name
Agency Fund
ION Payee Savemore

Office

Address
UACS
MFO/PAP Object Amount Responsibility Center Particulars
Code
103-00-1-00-00-000005-02-03-07 ₱ 1,650.00 MOOE - Food Supplies Expe

₱ 1,650.00

A.
Certified: Allotment available and obligated Certified: Charges to appropriation/alloment are
for the purpose/adjustment necessary as necessary, lawful and under my direct supervision;and
indicated above supporting documents valid, proper and legal

Printed Name:
_________________
Signature : ______________________________ Signature :
_________________ ___________________________________
Printed Name: ______________________________ __ ___________________________________
Head, Budget
Position : ______________________________
Division/Unit/Authorized Position : ___________________________________
Representative Head, Requesting Office/Authorized Representati
Date : ____________________________ Date : ___________________________________

TION C. STATUS O
Amount Reference
Balance
Payable Payment Due and
ORS/JEV/Check/
Not Yet DueDemanda Date Particulars
ADA/TRA No.
ble
(b) (c) (a-b) (b-c)
MOOE - Food Supplies Expense
 HSL AGENCY Date :June 11, 2021
Entity Name Fund Cluster : Regular
Agency Fund
e Payee

Office

Address
UACS
Particulars MFO/PAP Object Amount Responsibility Center
Code
MOOE - Food Supplies Expense 103-00-1-00-00-000005-02-03-05 ₱ 657.75

Total ₱ 657.75

B. A.
o appropriation/alloment are Certified: Allotment available and obligated
direct supervision;and for the purpose/adjustment necessary as
oper and legal indicated above

Printed Name:
_________________
___________________ Signature : ______________________________ Signature :
_________________
___________________ Printed Name: ______________________________ __
Head, Budget
___________________ Position : ______________________________
Division/Unit/Authorized Position :
Office/Authorized Representative Representative
___________________ Date : ____________________________ Date :

STATUS OF OBLIGATION C.
e Amount
Balance
Obligation Payable Payment Due and
ORS/JEV/Check/
Not Yet DueDemanda Date
ADA/TRA No.
ble
(a) (b) (c) (a-b) (b-c)
₱ 657.75
 HSL AGENCY Date :June 11, 2021
Entity Name Fund Cluster : Regular
Agency Fund
Payee Mercury Drug - Cotabato City Plaza

Office

Address
UACS
Responsibility Center Particulars MFO/PAP Object
Code
MOOE - Drugs and Medicine Expenses 103-00-1-00-00-000005-02-03-07

Total

B.
Certified: Charges to appropriation/alloment are Certified: Allotment available and obli
necessary, lawful and under my direct supervision;and for the purpose/adjustment necessary as
supporting documents valid, proper and legal indicated above

Printed Name:
_________________
Signature :
_________________ ___________________________________ Signature : ________________________
__ ___________________________________ Printed Name: ________________________
Head, Budget
Position : ___________________________________ Position : ________________________
Division/Unit/Authorized
Head, Requesting Office/Authorized Representative Representative
Date : ___________________________________ Date : ________________________

STATUS OF OBLIGATION
Reference Amount

ORS/JEV/Check/ Obligation Payable Payment

Particulars
ADA/TRA No.

(a) (b) (c)

MOOE - Drugs and Medicine Expenses ₱ 995.25
 Date :June 11, 2021 HSL AGENCY
Fund Cluster : Regular Entity Name
Agency Fund
Payee ANIMAL CLINIC

Office

Address

Amount Responsibility Center Particulars

₱ 995.25 MOOE - Other Professional Services

₱ 995.25 Total

A.
: Allotment available and obligated Certified: Charges to appropriation/alloment are
urpose/adjustment necessary as necessary, lawful and under my direct supervision;and
supporting documents valid, proper and legal

Printed Name:
_________________
______________________________ Signature :
_________________ ___________________________________
______________________________ __ ___________________________________
Head, Budget
______________________________
Division/Unit/Authorized Position : ___________________________________
Representative Head, Requesting Office/Authorized Representative
____________________________ Date : ___________________________________

C. STATUS OF OBLIGATION
ount Reference
Balance
Due and
ORS/JEV/Check/
Not Yet DueDemanda Date Particulars
ADA/TRA No.
ble
(a-b) (b-c)
MOOE - Other Professional Services
 Date :June 11, 2021 HSL
Fund Cluster : Regular En
Agency Fund
Payee

Office

Address
UACS
rs MFO/PAP Object Amount Responsibility Center
Code
ional Services 103-00-1-00-00-000005-02-11-99 ₱ 450.00

Total ₱ 450.00

B. A.
ent are Certified: Allotment available and obligated Certified:
d for the purpose/adjustment necessary as necessary, lawful and under my direct su
indicated above supporting documents valid, proper and

Printed Name:
_________________
_ Signature : ______________________________ Signature :
_________________ ________________________
_ Printed Name: ______________________________ __ ________________________
Head, Budget
_ Position : ______________________________
Division/Unit/Authorized Position : ________________________
Representative Head, Requesting Office/Au
_ Date : ____________________________ Date : ________________________

ATUS OF OBLIGATION C.
Amount Reference
Balance
Obligation Payable Payment Due and
Not Yet DueDemanda Date Particulars
ble
(a) (b) (c) (a-b) (b-c)
₱ 450.00 MOOE - Office Supplies Expense
 HSL AGENCY Date :June 11, 2021
Entity Name Fund Cluster : Regular
Agency Fund
FIESTA SHOPPING CENTER

UACS
Particulars MFO/PAP Object Amount
Code
MOOE - Office Supplies Expense 103-00-1-00-00-000005-02-03-01 ₱ 364.36

Total ₱ 364.36

B.
Charges to appropriation/alloment are Certified: Allotment available and obligated
, lawful and under my direct supervision;and for the purpose/adjustment necessary as
g documents valid, proper and legal indicated above

___________________________________ Signature : ______________________________

___________________________________ Printed Name: ______________________________
Head, Budget
___________________________________ Position : ______________________________
Division/Unit/Authorized
Head, Requesting Office/Authorized Representative Representative
___________________________________ Date : ____________________________

STATUS OF OBLIGATION
Reference Amount
Balance
Obligation Payable Payment Due and
ORS/JEV/Check/
Particulars Not Yet DueDemanda
ADA/TRA No.
ble
(a) (b) (c) (a-b) (b-c)
Office Supplies Expense ₱ 364.36
 HSL AGENCY
Entity Name

Payee DMC Petron Station

Office

Address

Responsibility Center Particulars MFO/PAP

MOOE - Fuel, Oil and Lubricant Expenses 103-00-1-00-00-00000

Total

A. B.
and obligated Certified: Charges to appropriation/alloment are
necessary, lawful and under my direct supervision;and
supporting documents valid, proper and legal

Printed Name:
_________________
______________ Signature :
_________________ ___________________________________ Signature :
______________ __ ___________________________________ Printed Name:
______________ Position : ___________________________________ Position :
Head, Requesting Office/Authorized Representative
____________ Date : ___________________________________ Date :

C. STATUS OF OBLIGATION
Reference Amount

ORS/JEV/Check/ Obligation Payable

Date Particulars
ADA/TRA No.

(a) (b)
MOOE - Fuel, Oil and Lubricant Expenses ₱ 500.00
 Date :June 11, 2021
Fund Cluster : Regular
Agency Fund

UACS
MFO/PAP Object Amount
Code
103-00-1-00-00-000005-02-03-07 ₱ 500.00

₱ 500.00

Certified: Allotment available and obligated

for the purpose/adjustment necessary as
indicated above

Signature : ______________________________
Printed Name: ______________________________
Head, Budget
Position : ______________________________
Division/Unit/Authorized
Representative
Date : ____________________________

TION
Amount
Balance
Payable Payment Due and
Not Yet DueDemanda
ble
(b) (c) (a-b) (b-c)