Appendix 11

OBLIGATION REQUEST AND STATUS Serial No. : _____________________

SCHOOLS DIVISION OF ALBAY Date : _________________________

Entity Name Fund Cluster : 101101

Payee JOSEPH B. BERNALDEZ

Office DEPED- DIVISION OF ALBAY
Address LEGAZPI CITY
Responsibility UACS Object
Particulars MFO/PAP Amount
Center Code

To obligate for the services rendered as AO II 5010101001 20,179.00

for the month of November 2018 as per 5010201001 2,000.00
suppporting documents attached hereto in the 5010301000 2,421.48
amount of… 5010302001 100.00
5010303001 277.46
5010304001 100.00

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: ROMEO C. BOÑON Printed NamALBERT B. BONAGUA, CPA

Position : Principal II Position Budget Officer III

Head, Requesting Office/Authorized Head, Budget Division/Unit/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)
 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