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BLGF form for disbursement voucher
Your Browser Doesn't Support Canvas. Showing the Text Content of the PDF Instead: Fund Cluster :
BUREAU OF LOCAL GOVERNMENT FINANCE
Entity Name
Regular Agency Fund
Date : Dec. 6, 2018
DV No. :
2018-12-
DISBURSEMENT VOUCHER
Mode of
Payment
MDS Check
Commercial Check
LDDAP-ADA
Others (Please specify)
_________________
TIN/Employee No.:
Payee
ORS/BURS No.:
Address
Responsibility
Center
Particulars
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
Traveling Expenses-Local
Debit
-
5 02 01 01 0 00
Cash-Modified Disbursement System (MDS), Regular
Credit
1 01 04 04 0 00
D. Approved for Payment
C. Certified:
Cash available
Subject to Authority to Debit Account (when applicable)
Supporting documents complete and amount claimed proper
Signature
Signature
Printed Name
JO ANN T. MENDOZA
Printed Name
JOCELYN T. PENDON
Position
Accountant III
Position
OIC-Executive Director
Date
E. Receipt of Payment
Check/ ADA
No. :
Signature :
Official Receipt No. & Date/Other Documents
Date
JEV No.
Date :
Bank Name & Account Number:
Date :
Printed Name:
Date
