DISBURSEMENT VOUCHER

SK of Barangay: BARANGAY VIGAN – SK DV No.:

City/Municipality: GEN. MAC ARTHUR Date :
Province: EASTERN SMAR
Payee:
Address:
TIN:
Particulars Amount

PURCHASED LED LIGHT 15,000

as per attached supporting paper, the amount of…..

300

TOTAL 14,700
A. Certified as to availability of the B. Certified as to C. Certified as to necessity,
budget or funds received for specific availability of cash, and validity, propriety, and legality
purpose completeness and of claim; and Approved for
propriety of supporting payment:
documents
HON. JOMMEL C. BAGARINO MARIVIC S. LACTAO HON. RAIEL Q. COLARDO
(Signature Over Printed Name) (Signature Over Printed
Budget Monitoring Officer (Signature Over Printed Name)
Name) SK Chairperson
SK Treasurer
Date : Date : Date :
D. Received Payment: Check No.:
Date:
Bank
Name:
Signature Over Printed Name of Payee/ Bank
Authorized Representative Branch:
OR No.:
Date Date:

E. Accounting Entries

ACCOUNT ACCOUNT CODE DEBIT CREDIT

15,000

BIR REMITTANCE

CASH IN BANK LCCA - LBP 300

TOTAL 180 14,700

Prepared by:

_______________________ Date:__________________

Barangay Bookkeeper

Approved by:

JOHN JERALD P. MIRANDA, CPA Date:__________

City/Municipal Accountant
 SK of Barangay
City/Municipality
Province

SK CHAIRPERSON’S CERTIFICATION
SKCC No.:
Date:

To: The Bank

Manager
(Name of Bank)
(Address)

Sir/Madam:
This is to certify that the following checks were duly issued by SK of Barangay ,
(Ito ay pagpapatunay na ang mga tseke na nakalista sa ibaba ay na-isyu ng SK ng Barangay

complete with respective Disbursement Vouchers and supporting documents.

na kompleto ng kani-kanilang Disbursement Vouchers at kalakip na mga dokumento.)

Account No. Check No. Date Payee Amount Purpose

The undersigned attests to the truthfulness of the foregoing facts, under pain of
(Pinapatotohanan ng may lagda ang mga nakasaad sa itaas batid ang

liability for falsification, pursuant to Article 171(4) of the Revised Penal Code of the
Philippines.
pananagutan sa kasong “Falsification”, sang-ayon sa Artikulo 171(4) ng Revised Penal Code ng Pilipinas.)

Very truly yours,

SK Chairperson

Delivered by: Received by:

SK Treasurer Bank Representative

Date: Date:

190
 LIQUIDATION REPORT LR No.:
SK of Barangay, City/Municipality, Province Date:
PARTICULARS AMOUNT

TOTAL AMOUNT SPENT

AMOUNT OF CASH ADVANCE PER DV NO. DTD.

AMOUNT REFUNDED PER O.R. NO. DTD.

AMOUNT TO BE REIMBURSED

A. Certified: Correctness of the B. Certified: Purpose of cash C. Certified: Supporting

above data advance duly accomplished documents are complete and
proper

Signature over Printed Name Signature over Printed Name Signature over Printed Name
Accountable SK Official SK Chairperson SK Treasurer

Date Date Date

190
 SK of Barangay, City/Municipality, Province

CERTIFICATION OF EXPENSES NOT REQUIRING RECEIPTS

Pursuant of COA Circular No. 2017-001 dated June 19,
2017

Name

Particulars Amount

TOTAL
Purpose

I hereby certify that the above expenses are incurred as they are necessary for the above cited purpose,
that above goods and services were acquired from parties not issuing receipts. And that I am fully
aware that willful falsification of statements is punishable by law.

Certified Correct by: Noted by:

Signature

Printed
Name

SK Official SK Chairperson
Date Date

190
 REIMBURSEMENT EXPENSE RECEIPT

SK of Barangay: RER No.:

City/Municipality: Date:
Province:

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

190
 PURCHASE REQUEST
SK of Barangay: PR No.:
City/Municipality: Date:
Province:
Unit of Estimated Estimated
Item No. Qty. Item description
Measurement Unit Cost Amount

Total Estimated Amount

Purpose:

Requested by: Approved by:

_
Signature over Printed Signature over Printed Name
Name Requesting SK SK Chairperson
Official

Date
Date

190
 INSPECTION AND ACCEPTANCE REPORT
SK of Barangay: IAR No.:
City/Municipality: Date:
Province:
Supplier: _ Invoice No.: _
PO No.: _ Date: Date:
Requesting SK Official:
Unit of
Item No. Item Description Quantity
Measurement

INSPECTION ACCEPTANCE

Date Inspected: _ Date Received:

Inspected, verified as to quantity Complete

and specifications

Partial (Pls. specify quantity

Received)

Signature over Printed Name Signature over Printed Name

Head, Inspection and Appraisal Committee SK Treasurer

190
 ACKNOWLEDGEMENT RECEIPT FOR DONATED PROPERTY AND
EQUIPMENT/SUPPLIES AND MATERIALS

SK of Barangay: ARDPE/SM No.:

City/Municipality: Date:
Province:
Donor’s Name:
Authorized Representative:
Address:

Unit of
Quantity Article Item Description Value
Measurement

Total

Purpose of Donation:

Received the donated articles for the purpose stated above.

_
Signature over Printed Name Date
SK Chairperson/Authorized SK Official

Conforme:

Signature over Printed Name Date

Donor/Authorized Representative

202
 ISSUE SLIP FOR DONATED PROPERTY AND EQUIPMENT/
SUPPLIES AND MATERIAL

SK of Barangay: ISDPE/SM No.:

City/Municipality: Date:
Province:
Recipient:
Address:

Unit of
Quantity Article Item Description Value
Measurement

Total
Purpose of Donation:

Approved by:

Signature over Printed Name Date

SK Chairperson/Authorized SK Official

Issued by:

_
Signature over Printed Name Date
SK Treasurer

Received by:

Signature over Printed Name Date

203
 Republic of the Philippines
Province of Eastern Samar
MUNICIPALITY OF GEN. MAC ARTHUR
Barangay VIGAN

-oOo-

ACKNOWLEDGMENT RECIEPT

WE HEREBY RECEIVED THE CASH PRIZES FOR VOLLEYBALL TOURNAMENT DURING

THE “PASKONG PALARO” HELD AT BARANGAY VIGAN ON DECEMBER 2021.

NAME PARTICULARS AMOUNT SIGNATURE DATE RECIEVED

FIRST PRIZE 2,000

SECOND PRIZE 1,500

THIRD PRIZE 1000

TOTAL AMOUNT

RAIEL Q. COLARDO

SK CHAIRPERSON

204
 PROVINCE OF EASTERN SAMAR
GENERAL MAC ARTHUR
BARANGAY VIGAN

SUMMARY OF TRAVEL EXPENSES

NAME DESIGNATION DESTINATION DATE PURPOSE TRAVEL AMOUNT

RAIEL Q. COLARDO SK CHAIRPERSON BORONGAN CITY DEC, 12, 2021 CANVAS SPORTS 1,150
(PAPA JOE HOUSE & GEN. MERCH.) EQUIPMENTS
MATERIALS
RAIEL Q. COLARDO SK CHAIRPERSON BORONGAN CITY DEC. 17, 2021 PURCHASE SPORTS 1,150
(PAPA JOE HOUSE & GEN. MERCH.) EQUIPMENTS
MATERIALS
RAIEL Q. COLARDO SK CHAIRPERSON GUIIUAN LBP JULY 15, 2021 OPENING SK BANK 500
ACCOUNT
MARIVIC S. LACTAO SK TREASURER GUIIUAN LBP JULY 15, 2021 OPENING SK BANK 500
ACCOUNT
MARIVIC S. LACTAO SK TREASURER GUIIUAN LBP NOV. 23, 2021 DEPOSIT 10% FUND TO 500
SK BANK ACCOUNT
RAIEL Q. COLARDO SK CHAIRPERSON GUIIUAN LBP DEC. 14, 2021 WITHRAW PRIZES 500

MARIVIC S. LACTAO SK TREASURER GUIIUAN LBP DEC. 14, 2021 WITHRAW PRIZES 500

TOTAL 4,800
 PURCHASE ORDER
SK of Barangay: City/Municipality:
Tel. No.: Province:
Supplier: PO No.:
Address: Date:
Tel. No.: TIN: Mode of Procurement:
Gentlemen: Please deliver to this office the following articles subject to the terms and conditions contained herein:
Place of Delivery: Delivery Term:
Date of Delivery: Payment Term:
Unit of
Item No. Item Description Quantity Unit Cost Amount
Measurement

(Total Amount in words)

In case of failure to make full delivery within the time specified above, a penalty of one-tenth (1/10) of one percent for every day of delay shall be imposed on
the undelivered item/s.
Conforme: Very truly yours,

Signature over Printed Name of Supplier Signature over Printed Name of SK Chairperson

Date Date
Availability of the budget or funds received for specific purpose:

Signature over Printed Name of Budget Monitoring Officer Date