Republic of the Philippines Fund Cluster:

Department of Agrarian Reform

Province of Capiz
Amado Lim Building, Roxas Avenue, Roxas City .
Date:

DISBURSEMENT VOUCHER DV No.:

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

Payment

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

Payee MARIBERT CORPORATION

Address Lawaan, Roxas City, Capiz

Responsibility
Particulars MFO/PAP Amount
Center

To payment of Fuel and other POL

Productsconsumed for the period of February ### PhP 44,865.25
1 - 28, 2019 as per supporting papers hereto
attached, in the amount of…

Amount Due PhP 44,865.25

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

GRACE M. TUNGUIA
PARPO I/OIC CAO-STOD
(Printed Name, Designation and Signature of Supervisor)

B. Accounting Entry:

Account Title UACS Code Debit Credit

C. Certified D. Approved for Payment:

Cash available

Subject to Authority to Debit Account (when applicable)

Supporting documents complete and amount claimed proper

Signature: Signature:

Printed Name: NORA MAE D. MAQUIRAN Printed Name: FELIX L. SERVIDAD

Provincial Accountant Provincial Agrarian Reform Program Officer II

Position: Position:
(Head; Accounting Unit/Authorized Representative) (Agency Head/Authorized Representative)

Date: Date:

E. Receipt of Payment: JEV No.

Check/ Bank Name & Account Number:
Date:
ADA No.:
Date: Printed Name: Date:
Signature:
MARIBERT CORPORATION

Official Receipt No. & Date/Other Documents

 OBLIGATION REQUEST AND STATUS
No:
DEPARTMENT OF AGRARIAN REFORM Date:
Agency Fund:

Payee MARIBERT CORPORATION

Office

Address Lawaan, Roxas City, Capiz

UACS Code/
Responsibility Center Particulars MFO/PAP Expenditure Amount

To Obligate Payment for Fuel & other

POL Products…

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

Signature Signature
Printed Name GRACE M. TUNGUIA Printed Name JOSEPHINE O. CONSING
Position PARPO I/OIC CAO - STOD Position BUDGET OFFICER
Head Requesting Office/Authorized Head Budget Unit/ Authorized
Representative Representative
Date Date

C. STATUS OF OBLIGATION
Reference Amount
Date Particulars ORS/JEV/RCI/RADAI No. Obligation Payment Not Yet Due Due and Demandable

Totals
 date particulars amount per head no. of pax amount
Oct. 19, 2016
Am Snacks: 75.00 10 750.00
Lunch: 250.00 10 2,500.00
Pm Snacks: 75.00 10 750.00
Dinner: 250.00 10 2,500.00
Function Room/ Venue Rental - - 4,000.00
Oct. 20, 2016 -
Am Snacks: 75.00 10 750.00
Lunch: 250.00 10 2,500.00
Pm Snacks: 75.00 10 750.00
Dinner: 250.00 10 2,500.00
Function Room/ Venue Rental - - 4,000.00
Oct. 21, 2016 -
Am Snacks: 75.00 10 750.00
Lunch: 250.00 10 2,500.00
Pm Snacks: 75.00 10 750.00
Function Room/ Venue Rental - - 3,713.00
28,713.00