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DISBURSEMENT VOUCHER HOUSE OF REPRESENTATIVES

Agency CLASSIFICATION OF DISBURSEMENT Regular Cash Advance Other Payment MDS Check

No.: Date:
MODE OF PAYMENT Commercial Check

Cash

Others

NAME OF CLAIMANT:

ID No./TIN:

ROSALINDA H. BORJA
ADDRESS: Human Resource Management Service Particulars Reimbursement of Extraordinary and Representation Expense incurred by Dir. II, HRMS for the month of SEPTEMBER 2006 as per various receipts and other supporting documents hereto attached in the amount of TWENTY THREE THOUSAND THREE HUNDRED EIGHTY FIVE PESOS ONLY.. Breakdown: 883 Extraordinary Expense 783 Representation Expense Total 15,675.00 7,710.00 23,385.00 Responsibility Center:

Amount Due
A Certified: Expenses/Advances necessary lawful and incurred under my direct Supervision C Approved for payment D Received Payment: P ______________

Jose Ma. Antonio B. Tuao Exec. Dir.-Admin Mgmt. Bureau


B Certified: Supporting documents Complete and proper, and cash available

TWENTY THREE THOUSAND THREE HUNDRED EIGHTY FIVE PESOS ONLY P 23,385.00 Amount

____________________________ _____ Signature Over Printed Name/Position Date

Check No.: Date :

HON. ROBERT ACE S. BARBERS Chairman, Ctte. on Accounts _____________________________________


Head of Agency/Authorized Representatives

Bank Name:

ELISA C. NAVALTA
Head, Accounting Unit NCA No.: ALOBS No.: JEV No.: Date

al Check

Cash

Others

No./TIN:

sponsibility Center:

Amount

23,385.00

23,385.00
Received Payment: P ______________

___________________________ _____

nature Over Printed Name/Position Date

________________________ ________________________ ________________________

V No.:

Date

SUMMARY OF EXPENSES

PAYEE

OR NO.

DATE

PLACE

AMOUNT GROCERY RESTAURANT

TOTAL

This is to certify that the total amount indicated above was actually incurred by me in connection with the performance of my official duties and functions as Executive Director IV

MA. MARGARITA T. SANTOS - ROA Executive Director IV