Appendix 44 Lr (1)
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LIQUIDATION REPORT
Serial No.: _________________
Period Covered : _______________
Date: _____________________ Responsibility Center Code:
Entity Name : Fund Cluster :
__________________________ PARTICULARS
OR DATE
OR Number
SUPPLIER NAME
AMOUNT
NATURE OF EXPENSE
TOTAL AMOUNT SPENT AMOUNT OF CASH ADVANCE PER DV NO.______DTD. ______ AMOUNT REFUNDED PER OR NO. _____________ DTD. ___________ AMOUNT TO BE REIMBURSED A Certified: Correctness of the above data ________________________ Signature Over Printed Name Claimant
B
Certified: Purpose of travel / cash advance duly accomplished
Signature Over Printed Name Immediate Supervisor
C Certified: Supporting documents complete and proper ________________________ Name of ADAS IN CHARGE Administrative Assistant III ________________________ Erwin M. Cruz Accountant III
Date: ______________________
Date: _______________ Date: _____________________
Serial No.: _________________
Period Covered : _______________
Date: _____________________ Responsibility Center Code:
Entity Name : Fund Cluster :
__________________________ PARTICULARS
OR DATE
OR Number
SUPPLIER NAME
AMOUNT
NATURE OF EXPENSE
TOTAL AMOUNT SPENT AMOUNT OF CASH ADVANCE PER DV NO.______DTD. ______ AMOUNT REFUNDED PER OR NO. _____________ DTD. ___________ AMOUNT TO BE REIMBURSED A Certified: Correctness of the above data ________________________ Signature Over Printed Name Claimant
B
Certified: Purpose of travel / cash advance duly accomplished
Signature Over Printed Name Immediate Supervisor
C Certified: Supporting documents complete and proper ________________________ Name of ADAS IN CHARGE Administrative Assistant III ________________________ Erwin M. Cruz Accountant III
Date: ______________________
Date: _______________ Date: _____________________
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