Appendix 11

OBLIGATION REQUEST AND STATUS Serial No. : _____________________

SCHOOLS DIVISION OF BOHOL Date : _________________________

Entity Name Fund Cluster : ___________________

Payee ARMAN MIASCO

Office DEPED Bohol Division
Address

UACS Object
Responsibility Center Particulars MFO/PAP Amount
Code
Reimbursement of Travelling Expenses
in the amount of FIVE THOUSAND THREE HUNDRED
FORTY SEVEN & 77/100 (P 5, 347.77) PESOS ……………… 5,347.77

Total 5,347.77
A. Certified: Charges to appropriation/alloment are B. Certified: Allotment available and obligated
necessary, lawful and under my direct supervision;and for the purpose/adjustment necessary as
supporting documents valid, proper and legal indicated above

Signature : ___________________________________ ______________________________

Printed Name: FERMIN M. ALBUTRA MA. VICTORIA M. JASPE

Administrative Officer V Position : Administrative Officer V

Head, Requesting Head, Budget Division/Unit/Authorized
Office/Authorized Representative Representative
Date : ___________________________________ Date : ____________________________

C. STATUS OF OBLIGATION
Reference Amount
Balance
ORS/JEV/Check/ Obligation Payable Payment Due and
Date Particulars Not Yet Due
ADA/TRA No. Demandable
(a) (b) (c) (a-b) (b-c)

42
 Proposed
REPORT OF CHECKS ISSUED
Period Covered: ________________
01/28
2014-01-028
Agency : JDG Department Report No.: ___________
Fund : 01
1234
Bank Name/Account No. _________________ 1
Sheet No.: _______________
Check DV No. / ORS/BUR Responsibility UACS Code/
Payee MFO/PAP/KRA Amount
Date No. Payroll No. Center Code Expenditure
1/28 023 2014-02-010 010 26-036-00-00000 ABC Corporation 3 01 01 0000 50604050 03 44,000 00
123

44,000 00

CERTIFICATION
I hereby certify that this Report of Checks Issued (RCI) in _________ sheet(s) is a full,
true and correct statement of all checks issued by me in payment for obligations for the period stated and
shown in the attached disbursement vouchers.
AO 6/15/02

Juan dela Cruz 01/29/14

Disbursing Date
Officer