Appendix 11
OBLIGATION REQUEST AND STATUS Serial No. : _____________________
_____________________________________ Date : _________________________
Entity Name Fund Cluster : ___________________
Payee
Office
Address
UACS Object
Responsibility Center Particulars MFO/PAP Amount
Code
Total
A. Certified: Charges to appropriation/alloment are B. Certified: Allotment available and obligated
necessary, lawful and under my direct supervision;and for the purpose/adjustment necessary as
supporting documents valid, proper and legal indicated above
Signature : ___________________________________ Signature : ______________________________
Printed Name: ____________________________________ Printed Name: ______________________________
Position : ____________________________________ Position : ______________________________
Head, Requesting Head, Budget Division/Unit/Authorized
Office/Authorized Representative Representative
Date : ___________________________________ Date : ____________________________
C. STATUS OF OBLIGATION
Reference Amount
Balance
ORS/JEV/Check/ Obligation Payable Payment Due and
Date Particulars Not Yet Due
ADA/TRA No. Demandable
(a) (b) (c) (a-b) (b-c)
42
Appendix 11
OBLIGATION REQUEST AND STATUS Serial No. :
Barangay Namal Date :
Municipality of Asipulo Fund Cluster: GOP
Payee CUM-BEL HARDWARE & CONSTRUCTION SUPPLY
Office POBLACION EAST, LAGAWE, IFUGAO
Address POBLACION EAST, LAGAWE, IFUGAO
UACS
Responsibility Center Particulars MFO/PAP Amount
Object Code
BRGY NAMAL TRUST Payment for Construction Materials for the KC-
ACCOUNT FOR PAMANA Cycle 3 Sub-project: Continuation of Beke-
PAMANA ₱ 45,781.37
Habiatan-Abbatan Sledge Trail
TOTAL ₱ 45,781.37
Certified: Charges to appropriation/allotment necessary, lawful Certified: Allotment available and obligated for the purpose/
and under my direct supervision; and supporting documents valid, adjustment necessary as indicated above.
proper and legal.
Signature : Signature :
Printed Name : HILDA A. BUMAHIT Printed Name : GRACE P. TAYABAN
Position : Barangay Treasurer Position : Punong Barangay
Date : Date :
STATUS OF OBLIGATION
Reference Amount
Balance
ORS/JEV/Check/ Obligation Payable Payment
Date Particulars Not Yet Due Due and Demandable
ADA/TRA No.
(a) (b) © (a-b) (b-c)
42
Appendix 11
OBLIGATION REQUEST AND STATUS Serial No. :
Barangay Namal Date :
Municipality of Asipulo Fund Cluster: GOP
Payee CUM-BEL HARDWARE & CONSTRUCTION SUPPLY
Office POBLACION EAST, LAGAWE, IFUGAO
Address POBLACION EAST, LAGAWE, IFUGAO
UACS
Responsibility Center Particulars MFO/PAP Amount
Object Code
BRGY NAMAL TRUST Payment for 4" CHB for the KC-PAMANA Cycle 3
ACCOUNT FOR Sub-project: Continuation of Beke-Habiatan-Abbatan
PAMANA ₱ 2,422.86
Sledge Trail
TOTAL ₱ 2,422.86
Certified: Charges to appropriation/allotment necessary, lawful Certified: Allotment available and obligated for the purpose/
and under my direct supervision; and supporting documents valid, adjustment necessary as indicated above.
proper and legal.
Signature : Signature :
Printed Name : HILDA A. BUMAHIT Printed Name : GRACE P. TAYABAN
Position : Barangay Treasurer Position : Punong Barangay
Date : Date :
STATUS OF OBLIGATION
Reference Amount
Balance
ORS/JEV/Check/ Obligation Payable Payment
Date Particulars Not Yet Due Due and Demandable
ADA/TRA No.
(a) (b) © (a-b) (b-c)
42
Proposed
REPORT OF CHECKS ISSUED
01/28
Period Covered: ________________
2014-01-028
Agency : JDG Department Report No.: ___________
Fund : 01 1234
Bank Name/Account No. _________________ 1
Sheet No.: _______________
Check DV No. / ORS/BUR Responsibility UACS Code/
Payee MFO/PAP/KRA Amount
Date No. Payroll No. Center Code Expenditure
1/28 023 2014-02-010 010 26-036-00-00000 ABC Corporation 3 01 01 0000 50604050 03 44,000 00
123
44,000 00
CERTIFICATION
I hereby certify that this Report of Checks Issued (RCI) in _________ sheet(s) is a full,
true and correct statement of all checks issued by me in payment for obligations for the period stated and
shown in the attached disbursement vouchers.
AO 6/15/02
Juan dela Cruz 01/29/14
Disbursing Date
Officer
