Appendix 46
REIMBURSEMENT EXPENSE RECEIPT
Entity Name: _________________ Fund Cluster : ________________
Date : _______________________ RER No. : ___________________
RECEIVED from ______________________________________
(Name)
_________________________________________________ the amount
(Official Designation)
of __________________________________________ (P__________)
(In Words) (in Figures)
in payment for _______________________________________________
(Payments for subsistence, services,
_________________________________________________________
rental or transportation should show inclusive dates,
_________________________________________________________
purpose, distance, inclusive points of travel, etc.)
PAYEE
Name/Signature __________________________________________
Address ________________________________________________
WITNESS
Name/Signature __________________________________________
Address ________________________________________________
123
Annex A Annex A
Republic of the Philippines Republic of the Philippines
CENTRAL BICOL STATE UNIVERSITY OF AGRICULTURE - SIPOCOT CENTRAL BICOL STATE UNIVERSITY OF AGRICULTURE - SIPOCOT
Impig, Sipocot, Camarines Sur Impig, Sipocot, Camarines Sur
CERTIFICATION OF EXPENSES NOT REQUIRING RECEIPTS CERTIFICATION OF EXPENSES NOT REQUIRING RECEIPTS
Pursuant to COA Circular No. 2017-001 dated June 19, 2017 Pursuant to COA Circular No. 2017-001 dated June 19, 2017
Name of Employee Name of Employee
Employee: No.: Employee: No.:
Office: Accounting Office Office: Accounting Office
Division: Division:
Particulars Amount (P) Particulars Amount (P)
TOTAL - TOTAL -
I hereby certify that the above expenses are incurred as they are necessary for the above I hereby certify that the above expenses are incurred as they are necessary for the above
cited purpose, that above goods and services were acquired from the parties not issuing cited purpose, that above goods and services were acquired from the parties not issuing
receipts. And that I am fully aware that willful falsification of statements is punishable by receipts. And that I am fully aware that willful falsification of statements is punishable by
law. law.
Certified Correct: Noted by: Certified Correct: Noted by:
Signature Signature
Printed Name Printed Name
Employee Imdediate Supervisor Employee Imdediate Supervisor
Date Date Date Date