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Appendix 44 Liquidation Report
FMB report form for liquidation
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LIQUIDATION REPORT
Serial No.: _________________
Period Covered ________________
Date: _____________________
Responsibility Center Code:
Entity Name : _____________________________________________
Fund Cluster : _____________________________________________
__________________________
PARTICULARS
AMOUNT
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
________________________
Signature over Printed Name
Head, Accounting Division Unit
JEV No.: ___________________
Date: ______________________
Date: _____________________
119
Date: _____________________
