Republic of the Philippines

Republic of the Philippines

PROVINCIAL GOVERNMENT OF CAPIZ

Capitol Building, Roxas City

DISBURSEMENT VOUCHERNo.

Mode of Payment Check Cash Others

PayeeWWILHon. Blesilda P. AlmalbisTIN/Employee No.Obligation Request No.

ADDDRESSS.P Pob. Pilar, Capiz Responsibility Center

Office/Unit Project Code

EXPLANATIONAMOUNT

To Reimbursement, My traveling expenses (Perdiem) while on monitoring of various projects in the different areas of my responsibility for the month of July, 2010. Chargeable to my travel Expenses Fund. As per supporting papers hereto attached with the total amount of.. Recommending for Approval:

Hon. Blesilda P. Almalbis Board Member

Province of Capiz Amount Due:

Allotment obligated for the purpose as

indicated above

Supporting documents complete

SignatureSignature

Printed NameERNIE B. ARCENASDatePrinted NameWENDIZIMA SUSTENTODate

PositionProvincial Accountant

Head, Requesting Office/Authorized RepresentativePosition Provincial Treasurer

Head, Budget Unit / Authorized Representative

C.Approved for PaymentD.Received Payment

SignatureCheck No.Bank NameDate

Printed NameHon. Esteban Evan B. ContrerasDateSignature

Vice Governor

Printed Name Hon. Blesilda P. Almalbis

PositionAgency Head/Authorized RepresentativeOR/Other DocumentsJEV No.Date

B

Certified

A

Certified

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