Appendix 48

No. : __________________ PETTY CASH VOUCHER

PETTY CASH VOUCHER
(PCV)
Entity Name : _____________________________ Date : _______________
Fund Cluster: _____________________________ INSTRUCTIONS

Payee/Office : ____________________________ Responsibility Center Code: A. The form shall be accomplished as follows: 10. Box B - Paid by – shall be signed by
the PCFC
Address : ________________________________ ______________________ 1. Entity Name – name of the agency/entity
2. Fund Cluster – the fund cluster 11. Box B - Cash Received by – shall be
name/code in accordance with the UACS signed by the recipient of cash
I. To be filled out upon request II. To be filled out upon liquidation 3. No. – number assigned to the PCV by the
PCFC. It shall be numbered as follows: II. To be filled out upon liquidation
Particulars Amount
0000- 0000-00-0000 12. Total Amount Granted – the amount
Total Amount Granted ______________ of cash received by the claimant
13. Total Amount Paid Per OR/Invoice
Serial number (one
Total Amount Paid per No. _______ – the total amount paid
series for each year)
as shown in the OR/invoice presented
OR/Invoice No. ______ ______________ Month 14. Amount Refunded/Reimbursed –
the difference between the total
Year
Amount Refunded/ amount granted less amount spent
(Reimbursed) Petty Cash 15. Box C – the PCFC shall check the
Custodian Code appropriate box for “Received
Refund” or “Reimbursement Paid”
A Requested by: C 3. Date – date of the preparation of PCV and affix his/her signature
Received Refund 4. Payee/Office and Address – 16. Box D – the payee shall check the
__________________________ name/office/address of payee/employee appropriate box for “Liquidation
Signature over Printed Name Reimbursement Paid requesting cash advance charged to the Submitted” and/or “Reimbursement
PCF Received by” and affix his/her
Name of Requestor signature
5. Responsibility Center Code – the cost/
responsibility center code of the requesting
Approved by: B. Part I shall be filled out upon request of
office
the petty cash advance and Part II shall be
__________________________ __________________________ filled out upon liquidation.
I. To be filled out upon request
Signature over Printed Name Signature over Printed Name
Name of Immediate Supervisor Petty Cash Custodian 6. Particulars – brief description of the C. The PCV shall be prepared in two copies
nature of disbursement/expense distributed as follows:
7. Amount – amount of petty cash requested
B Paid by: D Original – to be attached to the RPPCV
8. Box A – Requested by – shall be signed
by the Requestor together with the supporting
Liquidation Submitted documents
__________________________ 9. Box A – Approved by - shall be signed by
Copy 2 – PCFC file
Reimbursement Received by: the Immediate Supervisor of the Requestor
Signature over Printed Name
Petty Cash Custodian
Cash Received by:
__________________________ __________________________
Signature over Printed Name Signature over Printed Name
Payee Payee
Date: _______________ Date: _______________

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