General Form No. 74 (A) Revised Dec. 20, 1983

REPUBLIC OF THE PHILIPPINESCOMMISSION ON AUDIT

REPORT OF CASH EXAMINATIONName of Accountable Officer:

Position:

Agency: Station:

Maximum Accountability: Amount of Bond: Risk No:

Effective Date:

Auditor/Examiner: Official Designation:

A. CASH PRODUCTION NOTICE

TO: Accountable Officer:

Position: Date:

DEMAND, is hereby made that you produce all your cash, treasury warrants, checks, money orders, cash items, paid vouchers, unused accountable forms, etc., for which you are officially accountable as __________________________ of the________________________________ and any fund, checks, treasury warrants and/or cash items in your possession held by you for deposit and safekeeping.

NOTED AND COMPLIED WITH

Accountable Officer’s Signature: Date: Auditor/Duly Authorized Representative’s Signature:

INVENTORY OF CASH ON HAND INVENTORY OF CASH ITEMS

Paper and Coins: Particulars Amount

Denomina-tion

No. of Pcs.

Amount

Allowed Disallowed

Total, as presented Total, As Presented

B. TOTAL INVENTORY OF CASH AND/OR ALLOWED CASH ITEMS (TO D) ………………………………………..

C. INVENTORY OF UNUSED ACCOUNTABLE FORMS

With Money Value Without Money Value

Name of Form Qty Serial No. Denom. Amount Name of Form Qty Serial No.

CERT

I HEREBY CERTIFY on my official oath: (1) That upon demand by the Auditor/Examiner I produced all my cash, treasury warrants, checks, money orders, cash items, paid vouchers, unused accountable forms, etc., for which I am officially accountable; (2) That the inventory of such cash items and unused accountable forms in my possession and produced to the Auditor/Examiner at the time of cash count today ___________________ is correctly stated above and is broken down as follows: 1) Cash and/or cash items P __________ 2) Unused accountable forms with money value P _________ 3) Unused accountable forms without money value Pcs. _______of which ( P ) was disallowed by the Auditor/Examiner and (3) That said cash, treasury warrants, checks, money orders, cash items, paid vouchers, unused accountable forms, etc., were returned to me intact after the cash count.

Accountable Officer’s Signature:

Position:

Agency/Station:

Signed in the presence of:

D. STATEMENT OF ACCOUNTABILITY

Nature of Funds(1) (2) (3) (4) (5) (6)

TOTALS

BALANCE, Last Examination

(Date) ____________________

ADD: Debits to Accountability

Total Debits to Accountability

Less: Credits to Accountability

Total Credits to Accountability

Balance of Accountability as of

Inventory of Cash and/or allowed Cash Items

Shortage or (Overage)

CERTIFCATION

I HEREBY CERTIFY that my accountability for the above funds of ___________________________________________at the time of examination on ____________________________is correctly stated above totaling _________________________ ( P _______________________________)

Accountable Officer’s Signature

Designation:

Agency/Station:

I HEREBY CERTIFY that the preceding is true and correct report of the examination of the Cash and Accounts of:

Name of Accountable Officer:

Designation:

Agency/Station:

Date:

Remarks:

Signature of Auditor/Examiner: Date:

INSTRUCTIONS:

1. This form will be used for the examination of all cash accountable officers in the corporate, national and local government offices.2. Before proceeding to conduct examination, the examiner should thoroughly familiarize himself with the revised manual on cash examination.3. The six (6) columns on the face hereof are left blank to meet all fund requirements.4. If space provided for is not enough, use it as summary only and support it schedules. 5. All reports of examination with their supporting papers and letters will be forwarded to their respective Regional Directors in duplicate. In the

event of shortage/irregularity, the procedures outlined under COA Memorandum 83-81B dated November 1983 should be strictly followed.6. Checks, treasury warrants, money orders, and other cash items shall be listed on the space for Inventory of Cash Items.