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Form no: ADF 48 Form no: ADF 48

July 2017 July 2017


Rev. 00 Rev. 00

CERTIFICATION OF EXPENSES NOT REQUIRING RECEIPTS CERTIFICATION OF EXPENSES NOT REQUIRING RECEIPTS
Pursuant to COA Circular No. 2017-001 dated June 19, 2017 Pursuant to COA Circular No. 2017-001 dated June 19, 2017

Name of Employee Employee No. Name of Employee Employee No.

Office PLARIDEL WATER DISTRICT Office PLARIDEL WATER DISTRICT

Division Division
Particulars Amount (P) Particulars Amount (P)

Total Total

Purpose Purpose

I hereby certify that the above expenses are incurred as they are necessary for the above cited purpose, that above goods and I hereby certify that the above expenses are incurred as they are necessary for the above cited purpose, that above goods and
services were acquired from parties not issuing receipt. And that I am fully aware that willful falsification of statements is services were acquired from parties not issuing receipt. And that I am fully aware that willful falsification of statements is
punishable by law. punishable by law.
Certified Correct: Noted by: Certified Correct: Noted by:
Signature Signature

Printed Name Printed Name


Employee Immediate Supervisor Employee Immediate Supervisor
Date Date Date Date

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