Republic of the Philippines

PROVINCIAL GOVERNMENT OF CAPIZ

Capitol Building, Roxas City

DISBURSEMENT VOUCHER No.

Mode of
Check Cash Others
Payment
TIN/Employee Obligation Request No.
Payee
SMART No.
Responsibility Center
Address
Sangguniang Panlalawigan Office/Unit Project Code

EXPLANATION AMOUNT

To payment of my Cell phone bill for the month of August 5 to September 4, 2013 as
per supporting papers hereto attached in the total amount of . . . . . . . . .
P 2,879.47

HON. KAREN A. PALOMAR

Board Member
Province of Capiz

A Certified B Certified
Allotment obligated for the purpose as
Indicated above Funds Available

Supporting documents complete

Signature
Signature

Printed Date Printed Name Date

ERNIE B. ARCENAS WENDIZIMA S. SUSTENTO
Name
Provincial Accountant Provincial Treasurer
Position Position
Head, Requesting Office/Authorized Head, Budget Unit / Authorized
Representative Representative
C. Approved for Payment D. Received Payment
SMART

Check No. Bank Name Date

Signature

Date
Printed Signature
Name ESTEBAN B. CONTRERAS Printed Name Date

Vice-Governor OR/Other Documents JEV No. Date

Position
Agency Head/Authorized Representative
 Republic of the Philippines
PROVINCIAL GOVERNMENT OF CAPIZ
Capitol Building, Roxas City

OBLIGATION REQUEST No.

Payee SMART

Sangguniang Panlalawigan
OFFICE

Address Roxas City

Responsibility Account
Particulars F.P.P. Amount
Center Code

To payment of SMART P 2,879.47

Total
P 2,879.47

0 Certified
A B
Certified
Existence of available appropriation
Charges to appropriation/allotment necessary,
lawful and under my direct supervision
Supporting documents valid, proper and legal

Signature Signature

Printed Name Printed Name

HON. KAREN A. PALOMAR G. ANTONIO T. ARBIS

Board Member Provincial Budget Officer

Position Position
Head, Requesting Office/Authorized Head, Budget Unit / Authorized
Representative Representative
Date Date