LIQUIDATION REPORT Serial No.

: _________________
Period Covered ________________ Date: _____________________

Entity Name : BUREAU OF LOCAL GOVERNMENT FINANCE Responsibility Center Code:

Fund Cluster : Regular Agency Fund __________________________

PARTICULARS AMOUNT

TOTAL AMOUNT SPENT

AMOUNT OF CASH ADVANCE PER DV NO.______DTD. ______
AMOUNT REFUNDED PER OR NO. ________DTD. ___________
AMOUNT TO BE REIMBURSED
A Certified: Correctness of the B Certified: Purpose of travel / C Certified: Supporting documents
above data cash advance duly accomplished complete and proper

________________________ ________________________ ________________________

Signature over Printed Name Signature over Printed Name JO ANN T. MENDOZA
Claimant Immediate Supervisor Accountant III

JEV No.: ___________________

Date: ______________________ Date: _____________________ Date: _____________________

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