TEV

1 Routing Slip
2 Disbursement Voucher (duly signed by the Division Head)
3 Itinerary of Travel
4 Certificate of Travel Completed
5 Regional Special Order
6 Certificate of Apperance
 Appendix 32

DEPARTMENT OF HEALTH Fund Cluster :

Regional Office No. III 01
Date :
DISBURSEMENT VOUCHER DV No. :

Mode of MDS Check Commercial Check ADA Others (Please specify)

Payment

TIN/Employee No.: ORS/BURS No.:

Payee

PDO-TARLAC
Address

Responsibility
Particulars MFO/PAP Amount
Center

Payment of TEV for the month of

amounting to….

Charged to : Notice of Transfer of Cash Allocation

NTCA No. 053, NCA No. BMB-13-19-0000626

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

LAILANI P. MANGULABNAN, MD, MPH

Medical Officer V

B. Accounting Entry:
Account Title UACS Code Debit Credit

Traveling Expenses 5020101000

Subsistence Allowance 5010205000
Cash- MDS, Regular 1010404000

C. Certified: D. Approved for Payment

Cash available
Subject to Authority to Debit Account
Supp
proper

Signature Signature

Printed
JOYCE D. MALONZO, C.P.A Printed Name CESAR C. CASSION, MD, MPH, CESE
Name

Position Accountant - III Position Director IV

Date Date

E. Receipt of Payment JEV No.

Check/ Date : Bank Name & Account Number:
ADA No. :
Date : Printed Name: Date
Signature :
Official Receipt No. & Date/Other Documents

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 Appendix 45

ITINERARY OF TRAVEL

DEPARTMENT OF HEALTH - Regional Office No. III

Fund Cluster: 01 No.: _______________

Name : Date of Travel : FEBRUARY 2019

Position : Purpose of Travel : see attached RSO and ATT
Official Station : (Municipality)
TIME Means of Transpor- Per Total
Date Places to be visited Others
Departure Arrival Transportation station Diem Amount
From (Name of RHU) to 7:30 AM 8:00 AM PUJ 18.00 160.00 278.00
February 13, 2019
(Name of Brgy) and Return 4:30 PM 5:00 PM Tricycle 100.00
From (Name of RHU) to 7:30 AM 8:00 AM Tricycle 50.00 160.00 210.00
February 14, 2019
(Name of Brgy) and Return 4:30 PM 5:00 PM
From (Name of RHU) to 7:30 AM 8:00 AM PUJ 36.00 160.00 196.00
February 15, 2019
(Name of Brgy) and Return 4:30 PM 5:00 PM
From (Name of RHU) to 7:30 AM 8:00 AM PUJ 18.00 160.00 278.00
February 18, 2019
(Name of Brgy) and Return 4:30 PM 5:00 PM Tricycle 100.00
From (Name of RHU) to 7:30 AM 8:00 AM Tricycle 50.00 160.00 210.00
February 19, 2019
(Name of Brgy) and Return 4:30 PM 5:00 PM
From (Name of RHU) to 7:30 AM 8:00 AM PUJ 36.00 160.00 196.00
February 20, 2019
(Name of Brgy) and Return 4:30 PM 5:00 PM
From (Name of RHU) to 7:30 AM 8:00 AM PUJ 18.00 160.00 278.00
February 21, 2019
(Name of Brgy) and Return 4:30 PM 5:00 PM Tricycle 100.00
From (Name of RHU) to 7:30 AM 8:00 AM Tricycle 50.00 160.00 210.00
February 22, 2019
(Name of Brgy) and Return 4:30 PM 5:00 PM
From (Name of RHU) to 7:30 AM 8:00 AM PUJ 36.00 160.00 196.00
February 26, 2019
(Name of Brgy) and Return 4:30 PM 5:00 PM
From (Name of RHU) to 7:30 AM 8:00 AM PUJ 18.00 160.00 278.00
February 27, 2019
(Name of Brgy) and Return 4:30 PM 5:00 PM Tricycle 100.00
From (Name of RHU) to 7:30 AM 8:00 AM PUJ 36.00 160.00 196.00
February 28, 2019
(Name of Brgy) and Return 4:30 PM 5:00 PM

TOTAL 766.00 1,760.00 - 2,526.00

Prepared by :

I certify that : (1) I have reviewed the foregoing NAME

itinerary, (2) the travel is necessary to the service, (3) NDP
the period covered is reasonable and (4) the
expenses claimed are proper.
Approved by:

MARIA NOEL B. LIM, RN, MPH

MARIA NOEL B. LIM, RN, MPH OIC - DMO V
OIC - DMO V

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 Appendix 45

ITINERARY OF TRAVEL

DEPARTMENT OF HEALTH - Regional Office No. III

Fund Cluster: 01 No.: _______________

Name : LUZ P. LOPEZ Date of Travel :

Position : DMO V Purpose of Travel : see attached RSO and ATT
Official Station : PDO- Tarlac
TIME Means of Transpor- Per Total
Date Places to be visited Others
Departure Arrival Transportation station Diem Amount

TOTAL
Prepared by :

I certify that : (1) I have reviewed the foregoing LUZ P. LOPEZ, RN MSN
itinerary, (2) the travel is necessary to the service, (3) DMO V
the period covered is reasonable and (4) the
expenses claimed are proper.
Approved by:

EMILY V. PAULINO, MD, MPH

EMILY V. PAULINO, MD, MPH DMO V
DMO V

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 Appendix 46

REIMBURSEMENT EXPENSE RECEIPT

DOH - RO III Fund Cluster : 01

Date : RER No. : ___________________

RECEIVED from ______________________________________

(Name)

_________________________________________________ the amount

(Official Designation)

of __________________________________________ (P__________)
(In Words) (in Figures)

in payment for _______________________________________________

(Payments for subsistence, services,

_________________________________________________________
rental or transportation should show inclusive dates,

_________________________________________________________
purpose, distance, inclusive points of travel, etc.)
PAYEE
Name/Signature __________________________________________
Address ________________________________________________

WITNESS
Name/Signature __________________________________________
Address ________________________________________________

123