Checklist And New Dv Forms
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TEV 1 Routing Slip 2 Disbursement Voucher (duly signed by the Division Head) 3 Itinerary of Travel 4 Certificate of Travel Completed 5 Regional Special Order 6 Certificate of Apperance
Appendix 32 Fund Cluster :
DEPARTMENT OF HEALTH Regional Office No. III
01 Date : DV No. :
DISBURSEMENT VOUCHER Mode of Payment
MDS Check
Commercial Check
ADA
Others (Please specify)
TIN/Employee No.:
Payee
ORS/BURS No.:
PDO-TARLAC
Address
Responsibility Center
Particulars
MFO/PAP
Amount
Payment of TEV for the month of amounting to….
Charged to : Notice of Transfer of Cash Allocation NTCA No. 053, NCA No. BMB-13-19-0000626 Amount Due A. Certified: Expenses/Cash Advance necessary, lawful and incurred under my direct supervision. LAILANI P. MANGULABNAN, MD, MPH Medical Officer V B. Accounting Entry: Account Title
UACS Code
Traveling Expenses Subsistence Allowance Cash- MDS, Regular
Debit
Credit
5020101000 5010205000 1010404000
D. Approved for Payment
C. Certified: Cash available Subject to Authority to Debit Account Supp proper Signature
Signature
Printed Name
JOYCE D. MALONZO, C.P.A
Printed Name
CESAR C. CASSION, MD, MPH, CESE
Position
Accountant - III
Position
Director IV
Date E. Receipt of Payment Check/ ADA No. : Signature :
Date JEV No. Date :
Bank Name & Account Number:
Date :
Printed Name:
Official Receipt No. & Date/Other Documents
92
Date
Appendix 45 ITINERARY OF TRAVEL DEPARTMENT OF HEALTH - Regional Office No. III Fund Cluster: 01
No.: _______________
Name : Position : Official Station : (Municipality) Date
Places to be visited
February 13, 2019
From (Name of RHU) to (Name of Brgy) and Return
February 14, 2019
From (Name of RHU) to (Name of Brgy) and Return
February 15, 2019
From (Name of RHU) to (Name of Brgy) and Return
February 18, 2019
From (Name of RHU) to (Name of Brgy) and Return
February 19, 2019
From (Name of RHU) to (Name of Brgy) and Return
February 20, 2019
From (Name of RHU) to (Name of Brgy) and Return
February 21, 2019
From (Name of RHU) to (Name of Brgy) and Return
February 22, 2019
From (Name of RHU) to (Name of Brgy) and Return
February 26, 2019
From (Name of RHU) to (Name of Brgy) and Return
February 27, 2019
From (Name of RHU) to (Name of Brgy) and Return
February 28, 2019
From (Name of RHU) to (Name of Brgy) and Return
Date of Travel : FEBRUARY 2019 Purpose of Travel : see attached RSO and ATT TIME Departure Arrival 7:30 AM 8:00 AM 4:30 PM 5:00 PM 7:30 AM 8:00 AM 4:30 PM 5:00 PM 7:30 AM 8:00 AM 4:30 PM 5:00 PM 7:30 AM 8:00 AM 4:30 PM 5:00 PM 7:30 AM 8:00 AM 4:30 PM 5:00 PM 7:30 AM 8:00 AM 4:30 PM 5:00 PM 7:30 AM 8:00 AM 4:30 PM 5:00 PM 7:30 AM 8:00 AM 4:30 PM 5:00 PM 7:30 AM 8:00 AM 4:30 PM 5:00 PM 7:30 AM 8:00 AM 4:30 PM 5:00 PM 7:30 AM 8:00 AM 4:30 PM 5:00 PM
Means of TransporTransportation station PUJ 18.00 Tricycle 100.00 Tricycle 50.00
Per Diem 160.00
Others
160.00
210.00
PUJ
36.00
160.00
196.00
PUJ Tricycle Tricycle
18.00 100.00 50.00
160.00
278.00
160.00
210.00
PUJ
36.00
160.00
196.00
PUJ Tricycle Tricycle
18.00 100.00 50.00
160.00
278.00
160.00
210.00
PUJ
36.00
160.00
196.00
PUJ Tricycle PUJ
18.00 100.00 36.00
160.00
278.00
160.00
196.00
TOTAL
766.00
1,760.00
Prepared by : I certify that : (1) I have reviewed the foregoing itinerary, (2) the travel is necessary to the service, (3) the period covered is reasonable and (4) the expenses claimed are proper.
NAME NDP Approved by:
MARIA NOEL B. LIM, RN, MPH OIC - DMO V
MARIA NOEL B. LIM, RN, MPH OIC - DMO V
121
Total Amount 278.00
-
2,526.00
Appendix 45 ITINERARY OF TRAVEL DEPARTMENT OF HEALTH - Regional Office No. III Fund Cluster: 01
No.: _______________
Name : LUZ P. LOPEZ Position : DMO V Official Station : PDO- Tarlac Date
Places to be visited
Date of Travel : Purpose of Travel : see attached RSO and ATT TIME Departure Arrival
Means of TransporTransportation station
Per Diem
TOTAL Prepared by : I certify that : (1) I have reviewed the foregoing itinerary, (2) the travel is necessary to the service, (3) the period covered is reasonable and (4) the expenses claimed are proper.
LUZ P. LOPEZ, RN MSN DMO V Approved by:
EMILY V. PAULINO, MD, MPH DMO V
EMILY V. PAULINO, MD, MPH DMO V
121
Others
Total Amount
Appendix 46
REIMBURSEMENT EXPENSE RECEIPT
DOH - RO III
Fund Cluster :
01
Date :
RER No. : ___________________ RECEIVED from ______________________________________ (Name)
_________________________________________________ the amount (Official Designation)
of __________________________________________ (P__________) (In Words)
(in Figures)
in payment for _______________________________________________ (Payments for subsistence, services,
_________________________________________________________ rental or transportation should show inclusive dates,
_________________________________________________________ purpose, distance, inclusive points of travel, etc.)
PAYEE Name/Signature __________________________________________ Address ________________________________________________
WITNESS Name/Signature __________________________________________ Address ________________________________________________
123
Appendix 32 Fund Cluster :
DEPARTMENT OF HEALTH Regional Office No. III
01 Date : DV No. :
DISBURSEMENT VOUCHER Mode of Payment
MDS Check
Commercial Check
ADA
Others (Please specify)
TIN/Employee No.:
Payee
ORS/BURS No.:
PDO-TARLAC
Address
Responsibility Center
Particulars
MFO/PAP
Amount
Payment of TEV for the month of amounting to….
Charged to : Notice of Transfer of Cash Allocation NTCA No. 053, NCA No. BMB-13-19-0000626 Amount Due A. Certified: Expenses/Cash Advance necessary, lawful and incurred under my direct supervision. LAILANI P. MANGULABNAN, MD, MPH Medical Officer V B. Accounting Entry: Account Title
UACS Code
Traveling Expenses Subsistence Allowance Cash- MDS, Regular
Debit
Credit
5020101000 5010205000 1010404000
D. Approved for Payment
C. Certified: Cash available Subject to Authority to Debit Account Supp proper Signature
Signature
Printed Name
JOYCE D. MALONZO, C.P.A
Printed Name
CESAR C. CASSION, MD, MPH, CESE
Position
Accountant - III
Position
Director IV
Date E. Receipt of Payment Check/ ADA No. : Signature :
Date JEV No. Date :
Bank Name & Account Number:
Date :
Printed Name:
Official Receipt No. & Date/Other Documents
92
Date
Appendix 45 ITINERARY OF TRAVEL DEPARTMENT OF HEALTH - Regional Office No. III Fund Cluster: 01
No.: _______________
Name : Position : Official Station : (Municipality) Date
Places to be visited
February 13, 2019
From (Name of RHU) to (Name of Brgy) and Return
February 14, 2019
From (Name of RHU) to (Name of Brgy) and Return
February 15, 2019
From (Name of RHU) to (Name of Brgy) and Return
February 18, 2019
From (Name of RHU) to (Name of Brgy) and Return
February 19, 2019
From (Name of RHU) to (Name of Brgy) and Return
February 20, 2019
From (Name of RHU) to (Name of Brgy) and Return
February 21, 2019
From (Name of RHU) to (Name of Brgy) and Return
February 22, 2019
From (Name of RHU) to (Name of Brgy) and Return
February 26, 2019
From (Name of RHU) to (Name of Brgy) and Return
February 27, 2019
From (Name of RHU) to (Name of Brgy) and Return
February 28, 2019
From (Name of RHU) to (Name of Brgy) and Return
Date of Travel : FEBRUARY 2019 Purpose of Travel : see attached RSO and ATT TIME Departure Arrival 7:30 AM 8:00 AM 4:30 PM 5:00 PM 7:30 AM 8:00 AM 4:30 PM 5:00 PM 7:30 AM 8:00 AM 4:30 PM 5:00 PM 7:30 AM 8:00 AM 4:30 PM 5:00 PM 7:30 AM 8:00 AM 4:30 PM 5:00 PM 7:30 AM 8:00 AM 4:30 PM 5:00 PM 7:30 AM 8:00 AM 4:30 PM 5:00 PM 7:30 AM 8:00 AM 4:30 PM 5:00 PM 7:30 AM 8:00 AM 4:30 PM 5:00 PM 7:30 AM 8:00 AM 4:30 PM 5:00 PM 7:30 AM 8:00 AM 4:30 PM 5:00 PM
Means of TransporTransportation station PUJ 18.00 Tricycle 100.00 Tricycle 50.00
Per Diem 160.00
Others
160.00
210.00
PUJ
36.00
160.00
196.00
PUJ Tricycle Tricycle
18.00 100.00 50.00
160.00
278.00
160.00
210.00
PUJ
36.00
160.00
196.00
PUJ Tricycle Tricycle
18.00 100.00 50.00
160.00
278.00
160.00
210.00
PUJ
36.00
160.00
196.00
PUJ Tricycle PUJ
18.00 100.00 36.00
160.00
278.00
160.00
196.00
TOTAL
766.00
1,760.00
Prepared by : I certify that : (1) I have reviewed the foregoing itinerary, (2) the travel is necessary to the service, (3) the period covered is reasonable and (4) the expenses claimed are proper.
NAME NDP Approved by:
MARIA NOEL B. LIM, RN, MPH OIC - DMO V
MARIA NOEL B. LIM, RN, MPH OIC - DMO V
121
Total Amount 278.00
-
2,526.00
Appendix 45 ITINERARY OF TRAVEL DEPARTMENT OF HEALTH - Regional Office No. III Fund Cluster: 01
No.: _______________
Name : LUZ P. LOPEZ Position : DMO V Official Station : PDO- Tarlac Date
Places to be visited
Date of Travel : Purpose of Travel : see attached RSO and ATT TIME Departure Arrival
Means of TransporTransportation station
Per Diem
TOTAL Prepared by : I certify that : (1) I have reviewed the foregoing itinerary, (2) the travel is necessary to the service, (3) the period covered is reasonable and (4) the expenses claimed are proper.
LUZ P. LOPEZ, RN MSN DMO V Approved by:
EMILY V. PAULINO, MD, MPH DMO V
EMILY V. PAULINO, MD, MPH DMO V
121
Others
Total Amount
Appendix 46
REIMBURSEMENT EXPENSE RECEIPT
DOH - RO III
Fund Cluster :
01
Date :
RER No. : ___________________ RECEIVED from ______________________________________ (Name)
_________________________________________________ the amount (Official Designation)
of __________________________________________ (P__________) (In Words)
(in Figures)
in payment for _______________________________________________ (Payments for subsistence, services,
_________________________________________________________ rental or transportation should show inclusive dates,
_________________________________________________________ purpose, distance, inclusive points of travel, etc.)
PAYEE Name/Signature __________________________________________ Address ________________________________________________
WITNESS Name/Signature __________________________________________ Address ________________________________________________
123
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