No.

: 1
PETTY CASH VOUCHER
DEPARTMENT OF HEALTH REGIONAL OFFICE IV-A Date: March 6, 2017
FUND Cluster: 01
Payee/ Office: QUEZON PROVINCIAL DOH OFFICE Responsibility Center Code:
Address: 2nd Floor OPD Building QMC Compound Lucena City

I. To be filled out upon request II. To be filled out upon liquidation

Particulars Amount
Total Amount Granted 1,156.50
Payment of Oil (REV-X HD 155.10
40) and 31.69 Liters of Diesel 1,001.40
1,156.50
Total Amount Paid per
OR/ Invoice No. 11590/11589 1,156.50

Amount Refunded/
(Reimbursed)

Official Receipt
Trip Ticket
RPO
PR/ ER
Canvass (3)

A Requested by: C
Received Refund
CRIZALDY URZABIA
Signature over Printed Name Reimbursement Paid
Name of Requestor

Approved by:

JUVY PAZ P. PURINO, MD, MDM CRISTINA SJ. SAMADAN

Signature over Printed Name Signature over Printed Name
Name of Immediate Supervisor Petty Cash Custodian

B Paid by: D

CRISTINA SJ. SAMADAN Liquidation Submitted

Signature over Printed Name
Petty Cash Custodian Reimbursement Received by:

Cash Received by:

CRIZALDY URZABIA CRIZALDY URZABIA

Signature over Printed Name Signature over Printed Name
Payee Payee

Date: March 6, 2017 Date: March 7, 2017

 No.: 2
PETTY CASH VOUCHER
DEPARTMENT OF HEALTH REGIONAL OFFICE IV-A Date: March 7, 2017
FUND Cluster: 01
Payee/ Office: QUEZON PROVINCIAL DOH OFFICE Responsibility Center Code:
Address: 2nd Floor OPD Building QMC Compound Lucena City

I. To be filled out upon request II. To be filled out upon liquidation

Particulars Amount
Total Amount Granted 22,673.00
Payment of Photocopier
Repair/ Maintenance and 8,863.00
Toner (2) 13,810.00
Total Amount Paid per
OR/ Invoice No. 2074/2072/2073 22,673.00
22,673.00
Amount Refunded/
(Reimbursed)

Official Receipt
Trip Ticket
RPO
PR/ ER
Canvass (3)

A Requested by: C
Received Refund
__________________________
Signature over Printed Name Reimbursement Paid
Name of Requestor

Approved by:

JUVY PAZ P. PURINO, MD, MDM CRISTINA SJ. SAMADAN

Signature over Printed Name Signature over Printed Name
Name of Immediate Supervisor Petty Cash Custodian

B Paid by: D

CRISTINA SJ. SAMADAN Liquidation Submitted

Signature over Printed Name
Petty Cash Custodian Reimbursement Received by:

Cash Received by:

ARMANDO ARDIENTE ARMANDO ARDIENTE

Signature over Printed Name Signature over Printed Name
Payee Payee

Date: March 7, 2017 Date: March 7, 2017

 No.: 3
PETTY CASH VOUCHER
DEPARTMENT OF HEALTH REGIONAL OFFICE IV-A Date: March 8, 2017
FUND Cluster: 01
Payee/ Office: QUEZON PROVINCIAL DOH OFFICE Responsibility Center Code:
Address: 2nd Floor OPD Building QMC Compound Lucena City

III. To be filled out upon request IV. To be filled out upon liquidation
Particulars Amount
Total Amount Granted 973.19
Payment of 30.70 Liters of
Diesel 973.19
Total Amount Paid per
OR/ Invoice No. _______ 973.19

Amount Refunded/
(Reimbursed)

Official Receipt
Trip Ticket
RPO
PR/ ER
Canvass (3)

A Requested by: C
Received Refund
RAFAEL C. CADAVID
Signature over Printed Name Reimbursement Paid
Name of Requestor

Approved by:

JUVY PAZ P. PURINO, MD, MDM CRISTINA SJ. SAMADAN

Signature over Printed Name Signature over Printed Name
Name of Immediate Supervisor Petty Cash Custodian

B Paid by: D

CRISTINA SJ. SAMADAN Liquidation Submitted

Signature over Printed Name
Petty Cash Custodian Reimbursement Received by:

Cash Received by:

RAFAEL C. CADAVID RAFAEL C. CADAVID

Signature over Printed Name Signature over Printed Name
Payee Payee

Date: March 8, 2017 Date: March 8, 2017

 No.: 4
PETTY CASH VOUCHER
DEPARTMENT OF HEALTH REGIONAL OFFICE IV-A Date: March 7, 2017
FUND Cluster: 01
Payee/ Office: QUEZON PROVINCIAL DOH OFFICE Responsibility Center Code:
Address: 2nd Floor OPD Building QMC Compound Lucena City

III. To be filled out upon request IV. To be filled out upon liquidation
Particulars Amount
Total Amount Granted 848.00
Payment of 27.01 Liters of
Diesel 848.00
Total Amount Paid per
OR/ Invoice No. _______ 848.00

Amount Refunded/
(Reimbursed)

Official Receipt
Trip Ticket
RPO
PR/ ER
Canvass (3)

A Requested by: C
Received Refund
RAFAEL C. CADAVID
Signature over Printed Name Reimbursement Paid
Name of Requestor

Approved by:

JUVY PAZ P. PURINO, MD, MDM CRISTINA SJ. SAMADAN

Signature over Printed Name Signature over Printed Name
Name of Immediate Supervisor Petty Cash Custodian

B Paid by: D

CRISTINA SJ. SAMADAN Liquidation Submitted

Signature over Printed Name
Petty Cash Custodian Reimbursement Received by:

Cash Received by:

RAFAEL C. CADAVID RAFAEL C. CADAVID

Signature over Printed Name Signature over Printed Name
Payee Payee

Date: March 9, 2017 Date: March 9, 2017