_________________________________________ Fund Cluster:

Entity Name

DISBURSEMENT VOUCHER Date: 7/21/2021

DV No:

Mode of
Payment MDS Check Commercial Check ADA Others (Please Specify)

Payee TIN/Employee No: ORS/BURS No:

Address

Particulars Responsibility
Center MFO/PAP Amount

For the reimbursement of one (1) Printer-EPSON

L5190 MULTIFUNCTION PRINTER in the amount
of _________ P 13,700

P13,700
A
. Certified Expense/Cash Advance necessary. Lawful and incurred under my direct supervision.
___________________________________________
Printed Name, Designation and Signature of Supervisor

B Accounting Entry

Account Title UACS Code Debit Credit

Certified Approved for Payment

C D
Cash available

Subject to Authority Debit Account (when applicable)

Supporting documents complete and amount claimed proper

Signature Signature

Printed Name Printed Name

Position Position
Date Head,Accounting Unit Authorized Representative Date Agency Head/ Authorized Representative

E Receipt of Payment JEV No.

Check/ Date: Bank Name & Account Number

ADA No

Signature Date: Printed Name: Date:

Official Receipt No. & Date/ Other Documents