STATEMENT OF ACCOUNTABILITY FOR ACCOUNTABLE FORMS WITHOUT MONEY VALUE

As of October 5, 2016

Accountable Officer: SALVADOR ANDREW SALBORO

Designation: GEN. MANAGER / CASHIER
Agency: RIZAL WATER DISTRICT

Balance of
Balance on Hand On Hand Per Actual Count
NAME OF FORMS
Received Since Issued Since Accountability
January 1, 2013 October 5, 2016 Actual Count
QTY Incl. Serial No. QTY Incl. Serial No. QTY Incl. Serial No. QTY Incl. Serial No. QTY Incl. Serial No.

AF # 51 419 12082 - 12500 47 12082 - 12128

4 (12129-12132) cancelled
105 12133-12237 13 12238 - 12250 13 12238 - 12250
250 12251 - 12500*
10000 12501 - 22500 1092 12501 - 13592 8908 13593 - 22500 8908 13593 - 22500
Check
LBP Acct#
000512-1109-32 100 1761101 - 1761200 12 1761101 - 1761112 88 1761113 - 1761200 88 1761113 - 1761200

419 10100 1510 9009 9009

Prepared by: Reviewed by: I HEREBY CERTIFY that the Statement of Accountability fo
Forms withour Money Value is true and correct.

October 27, 2016 JINBOY A. PITOGO ANNABELLA C. UY October 27, 2016 SALVADOR ANDREW
Date State Auditor I/ATM State Auditor IV Date Accountable Off
OIC - Supervising Auditor
* The following series of Official Receipts were surrendered to BIR
RUSSEL VINCENT T. SARACHO November 13, 2013 as per advised of the latter. Such series of Offi
State Auditing Examiner II/ATM considered expired. As such, Rizal Water District was required to
updated Official Receipts.
 Difference

QTY Incl. Serial No.

untability for Accountable

ANDREW SALBORO
untable Officer

dered to BIR-Dipolog City on

eries of Official Receipts were
required to use the prescribed