Appendix 44

LIQUIDATION REPORT Serial No.: 2021-12

MINIMUM HEALTH STANDARD FUND-1ST TRANCHE Date: 12/09/2021

Entity Name : SDO ALAMINOS CITY Responsibility Center Code:

Fund Cluster : 01 070010801006

PARTICULARS AMOUNT

To liquidation of Health Essentials Fund

Other supplies and materials expenses 5020399000 28,055.93

Drugs and medicines 5020307000 9,688.59 37,744.52

TOTAL AMOUNT SPENT 37,744.52

AMOUNT OF CASH ADVANCE PER DV NO. _____ DTD _________ 47,400.00
AMOUNT REFUNDED PER OR NO. _____________ DTD. ________ -
AMOUNT TO BE REIMBURSED 9,655.48
A. Certified: Correctness of the above data B. Certified: Purpose of travel /cash advance C. Certified: Supporting documents
duly accomplished complete and proper

___________________________ ____________________________ _______________________

BERNARD P. BACOLCOL DR. LORNA G. BUGAYONG CESO V CHIMMY ANNE S. RAOET
Principal I Schools Division Superintendent Accountant III

JEV No.: _______________

Date: ______________________ Date: _____________________ Date: __________________
 Appendix 43
CASH DISBURSEMENTS REGISTER
Entity Name: DEPARTMENT OF EDUCATION Name of Accountable Officer:
Sub-Office/District/Division: Official Designation:
Municipality/City/Province: Alaminos City, Pangasinan Station:
Fund Cluster : 01 Register No. :
Sheet No. : 1 of 1

Advances for Operating

Expenses
(19901010)
DV/Payroll/
Date Particulars Amount
Other Supplies Repair &
OTHERS
Check No. Labor &
& Materials Maintenance -
Wages
Cash Expenses Bldgs. & OS Account UACS Object
Payments Balance Amount
Advance Description Code
5020399000 5021304001 5021601000
Cash Advance (MOOE downloading) 10,000.00
3,000.00 7,000.00 3,000.00
7,000.00
7,000.00
7,000.00

Totals - - 3,000.00 - - -
Account UACS Object
Amount
Description Code
Other Supplies 5020399000 3,000.00
Repair & Maint 5021304001 -
Labor & Wages 5021601000 -

Total -

CERTIFIED CORRECT: RECEIVED BY:

Name of School Head NELSON R. NACAR CPA

Designation Accountant III
Name of School
Date: Date:
 Maintenance and Other Operating Expenses

ACCOUNT CODE

Traveling Expenses-Local 5020101000

Training Expenses 5020201000
Office Supplies Expenses 5020301000
Accountable Forms Expenses 5020302000
Food Supplies Expenses 5020305000
Drugs and Medicines Expenses 5020307000
Fuel, Oil and Lubricants Expenses 5020309000
Semi-Expendable - Machinery and Equipment Expenses 5020321000
Semi-Expendable - Machinery 5020321001
Semi-Expendable - Office Equipment 5020321002
Semi-Expendable - ICT Equipment 5020321003
Semi-Expendable - Other Machinery and Equipment 5020321099
Semi-Expendable - Furniture and Fixtures 5020322001
Semi-Expendable - Other Supplies and Materials Expenses 5020399000
Water Expenses 5020401000
Electricity Expenses 5020402000
Postage and Courier Expenses 5020501000
Mobile 5020502001
Other Professional Services 5021199000
Janitorial Services 5021202000
Security Services 5021203000
Repairs and Maintenance - School Buildings 5021304002
Repairs and Maintenance - Other Structures 5021304099
Repairs and Maintenance - Machinery 5021305001
Repairs and Maintenance - Office Equipment 5021305002
Repairs and Maintenance - ICT Equipment 5021305003
Repairs and Maintenance - Other Machinery and Equipment 5021305099
Repairs and Maintenance - Furniture and Fixtures 5021307000
Repairs and Maintenance - SE Machinery 5021321001
Repairs and Maintenance - SE Office Equipment 5021321002
Repairs and Maintenance - SE ICT Equipment 5021321003
Repairs and Maintenance - SE Furniture & Fixtures 5021322000
Repairs and Maintenance - Other PPE 5021399099
Taxes, Duties and Licenses 5021501001
Fidelity Bond Premiums 5021502000
Insurance Expenses 5021503000
Printing and Publication Expenses 5029902000
Transportation and Delivery Expenses 5029904000
Other Maintenance and Operating Expenses 5029999002
APR FORM revised May 2015 FORM NO. 002
NAME AND ADDRESS OF AGENCY ACCT. CODE
REQUESTING AGENCY AGENCY CONTROL No.
TEL. NOS.

AGENCY PROCUREMENT REQUEST PS APR No.

To: PROCUREMENT SERVICE

DBM Compound, RR Road (Date Prepared)
Cristobal St., Paco, Manila

PLEASE CHECK (√ ) APPROPRIATE BOX ON ACTION REQUESTED ON THE ITEM/S LISTED BELOW

[ ] Please issue common-use supplies/materials per Price List No. __________________________ dated __________________________
Mode of delivery: [ ] Pick-up (Fast Lane) [ ] Pick-up (Schedule) [ ] Delivery (door-to-door)

In case fund is not sufficient:[ ] Reduce Quantity [ ] Bill Us [ ] Charge to Unutilized Deposit, APR No.:___________Date:________

[ ] Please purchase for our agency non-common items. Attached herewith :

[ ] Complete Specifications [ ] Obligation Request (ObR) [ ] Others, pls. specify_______________
[ ] Certificate of Budget Allocation (CBA) [ ] Payment _______________________________

This form shall be prepared for requisitions of Common-Use goods from the PS Depots & Sub-Depots; and for orders of Consumables
& Non-Common Use Supplies from the PS Main.
For PS Main-Common Use Supplies, please use Form 001 R or Form 001 B
ITEM ITEM AND DESCRIPTION/SPECIFICATIONS/STOCK No. QUANTITY UNIT UNIT PRICE AMOUNT
No.

TOTAL AMOUNT ₱ -
NOTE: ALL SIGNATURES MUST BE OVER PRINTED NAME
STOCKS REQUESTED ARE CERTIFIED TO BE FUNDS CERTIFIED AVAILABLE: APPROVED:
WITHIN APPROVED PROGRAM:

AGENCY HEAD/AUTHORIZED SIGNATURE

AGENCY PROPERTY/SUPPLY OFFICER AGENCY CHIEF ACCOUNTANT

[ ] FUNDS DEPOSITED WITH PS [ ] ___________________ CHECK No. ____________________

IN THE AMOUNT OF: ____________________________________________________________ (P _____________________) ENCLOSED
 Appendix 60

PURCHASE REQUEST

Entity Name: INERANGAN ELEMENTARY SCHOOL Fund Cluster : 01

Office/Section : PR No.: 2021-09- Date:
Responsibility Center Code : 070010801006 08/27/2021
Stock/ Property
Unit Item Description Quantity Unit Cost Total Cost
No.
1 pc Photocopy of MOOE liquidation and other school reports 1882 0.60 1,129.20
2 pc Tarpaulin (Brigada Eskwela, Precautionary measures) 4 187.75 751.00

1,880.20
Purpose:
For school & learners use.

Requested by: Approved by: Allotment Available:

Signature: ________________________ ____________________________ _________________________________
Printed Name: (Name of School Property Custodian) (Name of School Head) Helen A. Guillermo
Designation: School Property Custodian Budget Officer III

151
 Region I
Schools Division of Alaminos City
INERANGAN ELEMENTARY SCHOOL
Alaminos City, Pangasinan

REQUEST FOR QUOTATION

Date:
Quotation No.:

Sir/Madam:
Please quote your lowest price on the item/s listed below, subject to the general condition below stating
the shortest time of delivery and submit your quotation duly signed by your representative not later than
__________________in the return envelope attached herewith.
_______________________________
RUBY R. AQUINO
BAC Chairman
Note:
1. All entries must be type written, except for the prices quoted.
2. Delivery period within fifteen (15) days.
3. Warranty should be a period of six (6) months for supplies and materials; one(1) year
for procurement from date of acceptance by the procuring entity.
4. Price validity shall be a good for a period of seven calendar days.
5. G-EFS registration certification shall be attached upon submission of the quotation.
6. Bidders shall submit original brochures showing certification of the product being offered.

Item No. Quantity Unit Item and Description/Specification Unit Price Total Amount
1 4 cart Ink Cart (T6641), Black
2 4 cart Ink Cart (T6642), Cyan
3 4 cart Ink Cart (T6643), Magenta
4 4 cart Ink Cart (T6644), Yellow
5 2 ream Folder Long White
6 2 ream Folder Short White
7 5 ream Short Coupon bond Subs. 20
8 5 ream A4 Coupon bond Subs. 20
9 5 ream Long Coupon bond Subs. 20
10 4 pc Printer L120 model
11 4 box Paper Fastener
12 4 box Paper Clip
13 4 box Plastic Thumb Tacks
14 73 pc DepEd Medals
15 120 pc Ordinary Medals
16
17
18
19
20
21
22
23
24
25
Brand and Model :
Delivery Period :
Warranty :
Price Validity :

SUPPLIER'S GUARANTEE
After having carefully read and accepted your general conditions. I/We quote on the term at prices noted above.

Name of Company:
Address
Telephone/Fax No. Authorized Representative& Signature
 Region I
Inerangan Elementary School
INERANGAN ELEMENTARY SCHOOL
Alaminos City, Pangasinan
ABSTRACT OF PRICE QUOTATIONS OFFERED BY VARIOUS DEALERS
AND CERTIFICATE OF AWARD TO THE LOWEST BIDDERS/BIDDING
Project PR/RIS/JO No.
Purpose For school use Date 5/26/2020

UNIT PRICE QUOTED BY CORRESPONDING BIDDERS

Item No. Articles Pandayan Bookshop Abelens Sporting
CSI Alaminos
Inc. Goods
1 Ink Cart (T6641), Black 245.00 260.00
2 Ink Cart (T6642), Cyan 275.00 290.00
3 Ink Cart (T6643), Magenta 275.00 290.00
4 Ink Cart (T6644), Yellow 275.00 290.00
5 Folder Long White 570.00 377.50
6 Folder Short White 475.00 317.50
7 Short Coupon bond Subs. 20 182.40 185.25
8 A4 Coupon bond Subs. 20 176.00 191.75
9 Long Coupon bond Subs. 20 214.70 218.50
10 Printer L120 model 4,995.00 - 5,300.00
11 Paper Fastener 47.26 31.25
12 Paper Clip 29.45 22.00
13 Plastic Thumb Tacks 20.90 32.75
14 DepEd Medals 65.55 70.00 70.00
15 Ordinary Medals 37.05 38.00 38.00
16
17
18
19
20

TOTAL 7,883.31 2,614.50 5,408.00

CERTIFICATE OF COMMITTEE ON BID AWARDS

Based on Abstract of Price Quotations offered by dealers/bidders on various materials as quoted above, this
COMMITTEE, considering the lowest and reasonable price, hereby make the following awards to
Pandayan Bookshop Inc./ CSI Alaminos
DONE in this Office this 31st day of May, 2020.

BIDS AND AWARDS COMMITTEE

Signature
Name RUBY R. AQUINO ZENAIDA C. RAMOS LEAH A. TAMAYO ROSARIO R. AGOSTO ORLANDO B. ONIA
Position BAC Chairman BAC Member BAC Member BAC Member BAC Member
Date
 Appendix 61

PURCHASE ORDER
INERANGAN ELEMENTARY SCHOOL

Supplier : P.O. No. :

Address : Date :
TIN : Mode of Procurement : Shopping
Gentlemen:
Please furnish this Office the following articles subject to the terms and conditions contained herein:

Place of Delivery : Delivery Term :

Date of Delivery : Payment Term :

Stock/
Unit Description Quantity Unit Cost Amount
Property No.

(Total Amount in Words)

In case of failure to make the full delivery within the time specified above, a penalty of one-tenth (1/10) of one percent for every
day of delay shall be imposed on the undelivered item/s.

Conforme: Very truly yours,

__________________________
Signature over Printed Name of Supplier BERNARD P. BACOLCOL
___________________________ Principal I
Date

Allotment Available: ORS/BURS No.:

Date of the ORS/BURS:
Amount:

JEANNIE ROSE V. CABUNOT

Administrative Assistant III
 Appendix 62

INSPECTION AND ACCEPTANCE REPORT

Entity Name : INERANGAN ELEMENTARY SCHOOL Fund Cluster : 01

Supplier : IAR No. :

PO No./Date : Date :
Requisitioning Office/Dept. : Invoice No. :
Responsibility Center Code : Date :

Stock/
Description Unit Quantity
Property No.

INSPECTION ACCEPTANCE
Date Inspected : Date Received :

Inspected, verified and found in order as to Complete

quantity and specifications
Partial (pls. specify quantity)

________________________________________

________________________________________

________________________________________ School Property Custodian

________________________________________
 Appendix 33
PAYROLL
PROJECT TITLE:

Entity Name : INERANGAN ELEMENTARY SCHOOL Payroll No. :

Fund Cluster : 01 Sheet: 1 of 1
We acknowledge receipt of cash shown opposite our name as payment for the services rendered for the above-mentioned project.

No. of Deduction
Serial
Name Position Inclusive Dates Rate/Day Days Amount Due Net Amount Signature of Recipient Remarks
No.
Worked Absences
1 100.00 3 300.00 - 300.00
2 200.00 3 600.00 - 600.00
3 - - -
4 - - -
5 - - -
6 - - -
7 - - -
8 - - -
9 - - -
10 - - -
TOTAL 300.00 900.00 - 900.00
CERTIFIED: Services duly rendered as stated. APPROVED FOR PAYMENT:
A C
P 900.00

Date DR. LORNA G. BUGAYONG CESO V Date

BAC Chairman Schools Division Superintendent

CERTIFIED: Supporting documents complete and proper; CERTIFIED: Each employee whose name
B D E
and cash available in the amount of P appears on the payroll has been paid the amount ORS/BURS No. : __
as indicated opposite his/her name Date : ___________
JEV No. : ________
Date : ___________
CHIMMY ANNE S. RAOET Date BERNARD P. BACOLCOL
Accountant III Principal I

Page 10 of 16
 Department of Education
Region I
SCHOOL
School Address

PRE-REPAIR INSPECTION REPORT

Item / Description:
Property Number: Property Accountability Receipt
Acquisition Cost : Acquisition Date:
Nature and Scope of Last Repair , if any :

Complaints/Defects :

Parts /components to be Repaired / Replaced:

FINDINGS / OBSERVATIONS:

School Property Custodian

Date :

POST - REPAIR INSPECTION REPORT

Job Order No. Amount : Invoice No. Amount :

Findings/Comments:

School Property Custodian

Date :
 Appendix 45

ITINERARY OF TRAVEL

Entity Name :
Fund Cluster : 01 No.:

Name : Date/s of Travel:

Position : Purpose of Travel :
Official Station :
Places to be visited TIME Means of Transpor- Per Total
Date Others
(Destination) Departure Arrival Transportation station Diem Amount
from official station
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-

TOTAL - - - -
Prepared by :

I certify that : (1) I have reviewed the foregoing itinerary, (2) Name of Employee
the travel is necessary to the service, (3) the period covered is Designation
reasonable and (4) the expenses claimed are proper.

Approved by:

Name of Immediate Supervisor LORNA G. BUGAYONG PhD, CESO VI

Designation Schools Division Superintendent

121
 Appendix 46

REIMBURSEMENT EXPENSE RECEIPT

Entity Name: Fund Cluster : 01

Date : RER No. :

RECEIVED from ______________________________________

(Name)

_________________________________________________ the amount

(Official Designation)

of __________________________________________ (P__________)
(In Words) (in Figures)

in payment for _______________________________________________

(Payments for subsistence, services,

_________________________________________________________
rental or transportation should show inclusive dates,

_________________________________________________________
purpose, distance, inclusive points of travel, etc.)
PAYEE
Name/Signature __________________________________________
Address ________________________________________________

WITNESS
Name/Signature __________________________________________
Address ________________________________________________

123
 Department of Education
Schools Division of Alaminos City
SCHOOL
City of Alaminos, Pangasinan
ANNEX A
CERTIFICATION OF EXPENSES NOT REQUIRING RECEIPTS
Pursuant to COA Circular No. 2017-001- dated June 19, 2017

Name of Employee Employee No.

Station
Division SCHOOLS DIVISION OF ALAMINOS CITY
Particulars Amount ((₱)

Total -

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 receipts. And that I am fully aware that wilful falsification of
statements is punishable by law.
Certified Correct: Noted by:
Signature:
Printed Name:
Designation:
Employee Immediate Supervisor
Date Date
 Republic of the Philippines
For BIR BCS/ Department of Finance
Use Only Item: Bureau of Internal Revenue
BIR Form No.
Certificate of Creditable Tax
2307
January 2018 (ENCS)
Withheld at Source 2307 01/18ENCS
Fill in all applicable spaces. Mark all appropriate boxes with an "X".

1 For the Period From 07 01 2020 (MM/DD/YYYY) To 07 2020 (MM/DD/YYYY)

Part I – Payee Information

2 Taxpayer Identification Number (TIN) - - -

3 Payee’s Name (Last Name, First Name, Middle Name for Individual OR Registered Name for Non-Individual)

4 Registered Address 4A ZIP Code

Sta. Barbara, Pangasinan

5 Foreign Address, if applicable

Part II – Payor Information

6 Taxpayer Identification Number (TIN) 000 - 863 - 958 - 0 0 7 25

7 Payor’s Name (Last Name, First Name, Middle Name for Individual OR Registered Name for Non-Individual)

DEPARTMENT OF EDUCATION
8 Registered Address 8A ZIP Code

San Jose Drive, Poblacion, Alaminos City, Pangasinan 2404

Part III – Details of Monthly Income Payments and Taxes Withheld
AMOUNT OF INCOME PAYMENTS
Income Payments Subject to Expanded Tax Withheld for the
ATC 1st Month of the 2nd Month of the 3rd Month of the
Withholding Tax Total Quarter
Quarter Quarter Quarter
Income payments made by the government
to its local/resident suppliers of WI157
services

Income payments made by the government

to its local/resident suppliers of
goods WI640 1415.11 1415.11 14.16

Total 14.16
Money Payments Subject to Withholding
of Business Tax (Government & Private)
Persons exempt from VAT under
Sec. 109V (Creditable) -
Government Withholding Agent WB080

Total

We declare under the penalties of perjury that this certificate has been made in good faith, verified by us, and to the best of our knowledge and belief, is true and
correct, pursuant to the provisions of the National Internal Revenue Code, as amended, and the regulations issued under authority thereof. Further, we give our consent to
the processing of our information as contemplated under the *Data Privacy Act of 2012 (R.A. No. 10173) for legitimate and lawful purposes.

BERNARD P. BACOLCOL - Principal I

Signature over Printed Name of Payor/Payor’s Authorized Representative/Tax Agent
(Indicate Title/Designation and TIN)
Tax Agent Accreditation No./ Date of Issue Date of Expiry
Attorney’s Roll No. (if applicable) (MM/DD/YYYY) (MM/DD/YYYY)
CONFORME:

ROBERT C. CALIMLIM
Signature over Printed Name of Payee/Payee’s Authorized Representative/Tax Agent
(Indicate Title/Designation and TIN)
 Tax Agent Accreditation No./ Date of Issue Date of Expiry
Attorney’s Roll No. (if applicable) (MM/DD/YYYY) (MM/DD/YYYY)
*NOTE: The BIR Data Privacy is in the BIR website (www.bir.gov.ph)