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Republic of the Philippines

Fund Cluster:
Department of Justice
Land Registration Authority Date:
East Avenue, Diliman, Quezon City DV No:

DISBURSEMENT VOUCHER

Mode of MDS Check Commercial Check ADA Others (Please Specify)


Payment
TIN/Employee No: ORS/BURS No:

Payee

Address
Responsibility
Particulars Center MFO/PAP Amount

Amount Due

A. Certified: Expenses/Cash Advance necessary, lawful and incurred under my direct supervision.

_________________________________________
Printed Name, Designation and Signature of Supervisor
B. Accounting Entry
Account Title UACS Code Debit Credit

C. Certified D. Approved for Payment

Cash Available
Subject to Authority to Debit Account
(When Applicable)

Supporting Documents complete and


amount claimed proper
Signature Signature

Printed
Name JAIRUS M. CABUSI Printed Name
Chief, Accounting Division

Position Position
Head, Accounting Unit/Authorized Representative Agency Head/Authorized Representative
Date Date
E. Receipt of Payment JEV No.
Check/ Date: Bank Name & Account Number
ADA No:

Date: Printed Name: Date:


Signature

Official Receipt No. & Date/Other Documents

FINANS.FRM.2016.002
Revision 0/ 2016-01-06

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