Appendix 37

REPORT OF AUTHORITY TO DEBIT ACCOUNT ISSUED

Period Covered: ________________

LGU : _____________________________
Fund : ____________________________ Report No.: ___________________________
Bank Name/Account No. : ____________ Sheet No.: ____________________________
ADA DV/Payroll CAFOA
Payee Nature of Payment Amount
Date Serial No. No. No

CERTIFICATION

I hereby certify on my official oath that the above is a true statement of all ADAs issued by me during
the period stated above for which ADA Nos. ____________ to ___________ inclusive, were actually issued by me in the amounts shown thereon.

______________________________________________
Name and Signature of Local Treasurer
___________
Date