Republic of the Philippines

Province of Leyte

DISBURSEMENT VOUCHER No.

Mode of Payment Check Cash Other

Payee TIN/EMPLOYEE No. Obligation Request No.

Responsibility Center
Address Office/Unit/ code
Project
EXPLANATION AMOUNT

A. Certified B. Certified
Allotment obligated for the purpose as indicated
above Funds Available
Supporting documents complete
Date Date
Signature Signature

Printed Printed
Name Name
Position Position
Head, Accounting Unit/ Authorized Treasurer/ Authorized
Representative Representative
C. Approved for Payment D. Received Payment
Signature Check No Bank Name Date

Printed Signature
Name
Position Printed Date
Name
Or/ other Jev. NO. Date
Agency Head/ Authorized Representative
documents