Tarpaulin

PURCHASE REQUEST
Entity Name: Department of Education Fund Cluster: __________

Office/Section : PR No.: 2017- Date: July 10, 2017
Responsibility Center Code : __________________

Conversion Integrated School
Stock/ Property No. Unit Item Description Qty Unit Cost Total Cost
1 PC. TARPAULIN 1 336.00 336.00
TOTAL 336.00
Purpose: ____________________________________________________________
_______________________________________________________________
_______________________________________________________________
Requested by: Approved by:

________________________
Signature : _________________________
___
Printed Name : DONDY PASCUA EMERLINDA R. VILLA
Designation : PROPERTY CUSTODIAN SCHOOL HEAD/ Teacher
in charge
151
Department of Education
Region III
Schools Division of Nueva Ecija
District of Pantabangan
CONVERSION INTEGRATED SCHOOL - SECONDARY
REQUEST FOR QUOTATION

Date: 7/10/2017
Quotation Reference Number:
Sir/Madam:
Please quote your lowest price on the item/s listed below, stating the shortest time of delivery and submit your quotation thru email at
__________________ or fax at___________________ not later than ___________________
JOEY PASCUA EMERLINDA R. VILLA

Canvasser School Head
PROCUREMENT TERMS AND CONDITIONS

1. The Approved Budget for the Contract is PhP 336.00
2. Price quoted are subject to deduction of 5% VAT & 1% EWT (for goods) or 5%VAT & 2%EWT (for services)
3. Goods, supplies, equipment or work done are subject to inspection/acceptance, DepED reserves the right to cancel
reject or rebid the items which do not conform with the specifications.
4. Complete technical specifications, brand & model must be indicated in the price quotation for evaluation purposes.
5. Delivery period shall be indicated in the quotation. A liquidated damages equivalent to 1/10 of 1% per day
of delay for the value of undelivered items shall be imposed.
6. All bids in excess of the ABC will be rejected.
7. Supplier warrants that he/she has not given nor promised to give any money or gift to any DepEd employee to
secure this offer and to obtain an award.
Item No. Quantity Unit Item and Description Unit Price Total Amount
1 1 PC. TARPAULIN 336.00 336.00
*************** 336.00
Delivery Period: 7/13/2017

Warranty:
Price Validity:
Delivery Term: Pick up
Payment Term: Check
After having carefully read and accept your Procurement Terms & Conditions, I/We quote you on the item at prices
noted above.
4R MACAPAGAL ADVERTISING & FURNITURE

PRINTED NAME/SIGNATURE
Designation:
Company Name: 4R MACAPAGAL ADVERTISING & FURNITURE
Business Address: 084 Del Pilar St., Sangitan West Cabanatuan City
Telephone Number/CP number: 463-7971
Email Address:
Region III
Conversion Integrated School - Secondary

Date: 7/10/2017
Sir/Madam:

Canvasser School Head/HT-1

1 1 PC. TARPAULIN 355.00 355.00
*************** 355.00

Warranty:
Price Validity:
Payment Term: Check
noted above.
FERNANDO C. PAYAWAL ADVERTISING

Designation:
Company Name: FERNANDO C. PAYAWAL ADVERTISING
Business Address: Gabaldon St., cor. Ma. Theresa Subd. Cabanatuan City, N.E
Telephone Number/CP number:
Email Address:
Region III

Date: 7/10/2017
Sir/Madam:

Canvasser School Head/HT-1

1 1 PC. TARPAULIN 385.00 385.00
*************** 385.00

Warranty:
Price Validity:
Payment Term: Check
noted above.
MONSAR STUDIO
Designation:
Company Name: MONSAR STUDIO
Business Address: Rizal, Nueva Ecija
Telephone Number/CP number:
Email Address:
Region III
Conversion Integrated School-Secondary
ABSTRACT OF CANVASS BID

FOR THE TARPAULIN PRINTING
Held on July 10, 2017
4R MACAPAGAL
FERNANDO C. PAYAWAL
ADVERTISING & MONSAR STUDIO
QTY UNIT ARTICLES ADVERTISING
FURNITURE
UNIT PRICE TOTAL UNIT PRICE TOTAL UNIT PRICE TOTAL
1 PC. TARPAULIN 336.00 336.00 355.00 355.00 385.00 385.00
TOTAL TOTAL 336.00 355.00 385.00
Recommending award to 4R MACAPAGAL Advertising & Furniture

Prices considered just and reasonable and does not exceed the prices prevailing in the locality.
MARITES T. BALDEREZ DONDY PASCUA EMERLINDA R. VILLA

School Treasurer School Property Custodian School Head
Region III
PURCHASE ORDER
Supplier : 4R MACAPAGAL ADVERTISING & FURNITURE P.O. No. : ____________________________
Address : Cabanatuan City, Nueva Ecija Date : July 12, 2017
TIN : 253-209-147-000 Mode of Procurement : Check
Gentlemen:
Please furnish this Office the following articles subject to the terms and conditions contained herein:
Place of Delivery : Conversion Integrated School - Secondary Delivery Term : Pick up

Date of Delivery : July 13, 2017 Payment Term : Check
Stock/ Property
Unit Description Quantity Unit Cost Amount
No.
1 PC. TARPAULIN 1 336.00 336.00
(Total Amount in Words) THREE HUNDRED THIRTY SIX PESOS ONLY
In case of failure to make the full delivery within the time specified above, a penalty of one-tenth (1/10) of one percent for every day of delay
shall be imposed on the undelivered item/s.
Conforme: Very truly yours,
4R MACAPAGAL ADVERTISING & FURNITURE EMERLINDA R. VILLA

Signature over Printed Name of Supplier Signature over Printed Name of School Principal/Teacher
in Charge
7/13/17 School Head

Date Designation
Fund Cluster : ___________________________________ ORS/BURS No. : ______________________

Funds Available : _________________________________ Date of the ORS/BURS: _______________
Amount : ____________________________
MARITES T. BALDEREZ
Signature over Printed Name of Disbursing officer/School
Treasurer
153
Region III
Conversion Integrated School-Secondary
INSPECTION AND ACCEPTANCE REPORT
Fund Cluster :
Supplier : 4R MACAPAGAL ADVERTISING & FURNITURE IAR No. : _______________

PO No./Date : Date : July 13,2017
Requisitioning Office/Dept. : _______________________________ Invoice No. :
Responsibility Center Code : _______________________________ Date :
Stock/
Description Unit Quantity
Property No.
1 TARPAULIN PC. 1
INSPECTION ACCEPTANCE
Date Inspected : _______________________ Date Received : _____________________
Inspected, verified and found in / Complete

/ order as to quantity and
specifications Partial (pls. specify quantity)
JENNIFER J. PASCUA DONDY PASCUA

Inspection Officer/Inspection Committee Supply and/or Property Custodian
Region III
Fund Cluster : 01101101

Date : July 13, 2017
DISBURSEMENT VOUCHER
DV No. :
Mode of MDS Check / Commercial Check ADA Others (Please specify)

Payment
_________________
TIN/Employee No.: ORS/BURS No.:
Payee 4R MACAPAGAL ADVERTISING & FURNITURE
000-000-000
Address Cabanatuan City, Nueva Ecija
Particulars Responsibility Center MFO/PAP Amount
Payment for Tarpaulin for Nutrition Month
GROSS AMOUNT P 336.00
Tax Withheld (Vat Reg.)

5% 15.00
1% 3.00 18.00
Amount Due P 318.00

A. Certified: Expenses/Cash Advance necessary, lawful and incurred under my direct supervision.
EMERLINDA R. VILLA
School Head/ Teacher in charge
B. Accounting Entry:
Account Title UACS Code Debit Credit
Advances for Operating Expenses 1990104000 318.00
Cash MDS - Regular 1010404000 318.00
TOTAL 318.00 318.00
C. Certified: D. Approved for Payment
Cash available
Subject to Authority to Debit Account (when applicable)
THREE HUNDRED EIGHTEEN PESOS ONLY
Su
proper
Signature Signature
Printed
Printed Name
Name MARITES T. BALDEREZ EMERLINDA R. VILLA
Position Disbursing Officer/Treasurer Position School Head/Teacher in Charge
Date Date
E. Receipt of Payment JEV No.

Check/ Date : Bank Name & Account Number:
ADA No. :
Date : Printed Name: Date
Signature :
Official Receipt No. & Date/Other Documents
92
BIR Form No.
Certificate of Final Tax
2306
Republika ng Pilipinas
Kagawaran ng Pananalapi
Kawanihan ng Rentas Internas
Withheld At Source
March 2003 (ENCS)
1 For the Period
From (MM/DD/YY) To (MM/DD/YY)
Part I Income Recipient/Payee Information Withholding Agent/Payor Information
2 TIN 3 TIN 450 812 383 000
253 209 147 000
4 Payee's Name (For Non-Individuals ) 5 Payor's Name (For Non- Individuals)
4R MACAPAGAL ADVERTISING & FURNITURE CONVERSION INTEGRATED SCHOOL
6 Payee's Name (Last Name, First Name, Middle Name) For Individuals 7 Payor's Name (Last Name, First Name, Middle Name) For Individuals
8 Registered Address 9 Registered Address

CABANATUAN CITY, NUEVA ECIJA CONVERSION, PANTABANGAN, NUEVA ECIJA
8A Zip 9A Zip 3124
Code Code
10 Foreign Address 10A Zip Code 10B ICR No. (For Alien Income Recipient Only)
Part II Details of Income Payment and Tax Withheld

Nature of Income Payment ATC Amount of Payment Tax Withheld
VAT on Purchase of Goods 336.00 15.00
Total 336.00 15.00

We declare, under the penalties of perjury, that this certificate has been made in good faith, verified by us, and to the best of our knowledge and belief, is true and
correct pursuant to the provisions of the National Internal Revenue Code, as amended, and the regulations issued under authority thereof.
11 EMERLINDA R. VILLA
Payor/Payor's Authorized Representative Date Signed
Signature Over Printed Name
CONFORME 4R MACAPAGAL ADVERTISING &
12 FURNITURE Date Signed
Payee/Payee's Authorized Representative
To be accomplished for Value-Added Tax/Percentage Tax Withholding (substituted filing)
I declare, under the penalties of perjury, that the information I declare under the penalties of perjury that I am qualified under substituted filing of Percentage
herein stated are reported under BIR Form No. 1600 which Tax/Value Added Tax Returns (BIR Form 2551M/2550M/Q), since I have only one payor from
have been filed with the Bureau of Internal Revenue. whom I earn my income; that, in accordance with RR 14-2003, I have availed of the Optional
Registration under the 3% Final Percentage Tax Wthholding/10% Final VAT Withholding in lieu
of the 3% Percentage Tax/10% VAT in order to be entitled to the privileges accorded by the
Substituted Percentage Tax Return/Substituted VAT Return System prescribed in the aforesaid
Regulations; that, this Declaration is sufficient authority of the withholding agent to withhold 3%
Final Percentage Tax/10% Final VAT from my sale of goods and/or services.
13 14
Payor/Payor's Authorized Representative Payee/Payee's Authorized Representative

Signature Over Printed Name Signature Over Printed Name
BIR Form No.
Republika ng Pilipinas
Certificate of Creditable
Kagawaran ng Pananalapi
Kawanihan ng Rentas Internas
Tax Withheld At Source 2307
March 2003 (ENCS)
1 For the Period

From (MM/DD/YY) To (MM/DD/YY)
Part I Payee Information
2 Taxpayer
253 209 147 000
Identification Number
3 Payee's Name 4R MACAPAGAL ADVERTISING & FURNITURE
(Last Name, First Name, Middle Name for Individuals) (Registered Name for Non-Individuals)
4 Registered Address CABANATUAN CITY, NUEVA ECIJA 4A Zip Code
5 Foreign Address 5A Zip Code
Payor Information
6 Taxpayer
450 812 383 000
Identification Number
7 Payor's Name CONVERSION INTEGRATED SCHOOL
(Last Name, First Name, Middle Name for Individuals) (Registered Name for Non-Individuals)
8 Registered Address Conversion, Pantabangan, Nueva Ecija 31
8A Zip Code 24
PART II Details of Monthly Income Payments and Tax Withheld for the Quarter
Income Payments Subject to
ATC
Expanded Withholding Tax 1st Month of 2nd Month of 3rd Month of Tax Withheld
Total
the Quarter the Quarter the Quarter For the Quarter
VAT ON PURCHASED OF 336.00 3.00
GOODS
Total 336.00 3.00

Money Payments Subject to Withholding
of Business Tax (Government & Private)
Total
We declare, under the penalties of perjury, that this certificate has been made in good faith, verified by me, and to the best of my knowledge and belief, is true and correct,
pursuant to the provisions of the National Internal Revenue Code, as amended, and the regulations issued under authority thereof.
9 EMERLINDA R. VILLA 10 School Head
Payor/Payor's Authorized Representative Title/Position of Signatory
(Signature Over Printed Name)
Conforme:
4R MACAPAGAL ADVERTISING & FURNITURE
Payee/Payee's Authorized Representative Date Signed

DEPARTMENT OF EDUCATION
DIVISION OF NUEVA ECIJA
MASUNURIN ELEMENTARY SCHOOL
SAN LEONARDO DISTRICT, NUEVA ECIJA
FOR THE MONTH OF JUNE 2017
CASH DISBURSEMENT REGISTER
WORKING FUND 5020101000 5020201000 5020301000 5020307000 5020399000 5020401000 5020402000 5020503000 5021299000 5021203000 5021202000 5021304002 5021299000 5021307000 5021304099 5021502000 5029999002 2020101000
Date of No. Of Check Gross Tax
Check PAYEE Particulars CASH FUND Internet Rep&Main- Rep&Main- Fidelity
Issued Amount withheld PAYMENT Training Office Drugs, Other Other Security Janitorial Rep&Main- Rep&Main-IT
Issued ADVANCE BALANCE Travelling Ex.
Expenses Supplies Ex. Medicine Ex. Supplies Ex.
Water Ex. Electricity Ex. Subscription
Gen.Services Services Services Schl.Bldg. EQ.
Furniture & Other Bond Other MOOE Due to BIR
Expenses Fixtures Structures Premium
LBP ACCOUNT FORWARDED BALANCE 4,737.01

MOOE DOWNLOADING FOR THE 26,020.00 30,757.01
MONTH OF JUNE 2017
Reimbursement for traveling
6/3/2017 10001 VYA G. REYES expenses for the month of May 1,500.00 1,500.00 29,257.01 1,500.00
2017
Reimbursement for registration
6/6/2017 10002 MICHELLE M. fee on WPAD workshop dtd 2,000.00 2,000.00 27,257.01
SAMANIEGO 05/31/17 2,000.00
Payment for office supplies, OR#
6/6/2017 10003 BELBEL TRADING 333515 dtd 6/5/17 3,000.00 190.45 2,809.55 24,447.46
3,000.00
Payment for monthly medical
6/6/2017 10004 ARLYN MEDICS INC supplies, OR#353586 dtd 06/5/17 2,065.00 82.60 1,982.40 22,465.06
2,065.00
Payment for the purchase of
6/6/2017 10005 DAN IT SHOP printer and scanner, OR#2525 dtd 5,000.00 267.86 4,732.14 17,732.92
06/06/17
5,000.00
Payment for water expense for
6/6/2017 10006 PRIMELULU WATER the period 05/05-06/05/17, 3,565.00 178.25 3,386.75 14,346.17
INC OR#5858 dtd 06/06/17
3,565.00
Payment for electricity expense for
6/6/2017 10007 NEECO II the period 05/05-06/05/2017, 3,500.00 218.75 3,281.25 11,064.92
OR#75906258 dtd 6/6/17 3,500.00
Payment for internet subscription
6/6/2017 10008 GLOBE TELECOM for the period of 05/05- 1,000.00 50.00 950.00 10,114.92
06/05/2017, OR#3535 dtd 6/6/17 1,000.00
Payment for Security Services for
6/6/2017 10009 RENREN ESPANTO the month of June 2017 1,350.00 1,350.00 8,764.92
1,350.00
Payment of purchases of
AILEEN construction materials for ceiling
6/6/2017 10010 repair, OR#2525 dtd 06/05/17 1,250.00 50.00 1,200.00 7,564.92
CONSTRUCTION
1,250.00
Payment of labor for repainting of
LUCILLE fences dtd 05/31/17
6/6/2017 10011 ANAWANGIN 950.00 950.00 6,614.92
950.00
Reimbursement for payment of
6/6/2017 10012 DANG JAVIER Fidelity bond for the period of 562.50 562.50 6,052.42
06/01/17 to 06/02/18
562.50
Payment for printing of tarpaulin
for BRIGADA ESKUWELA 2017,
6/6/2017 10013 JONA TARPO SHOP OR#21825114 dtd 6/6/17 2,500.00 156.25 2,343.75 3,708.67
2,500.00
Payment for photocopy of School
AKUSAKI forms, OR#222 dtd 6/6/17
6/6/2017 10014 photoshop 1,514.51 514.00 1,000.51 2,708.16
Payment of tax withheld (BIR

6/6/2017 10015 BIR FORM 1600) 1,024.89 1,683.27
Payment of tax withheld (BIR

6/6/2017 10016 BIR FORM 1601) 683.27 1,000.00
TOTAL 29,757.01 1,708.16 30,757.01 29,757.01 1,000.00
Certified Correct: Certified Correct: Approved:

MARAH M. PACSON RONALDO A. POZON, Ph.D., CESO V
SCHOOL HEAD DIVISION ACCOUNTANT SCHOOLS DIVISION SUPERINTENDENT
DATE DATE DATE
LIQUIDATION REPORT No:
Date:
Department of Education Responsibility Center
Sama-Sama Region III Code:
sa DepEd
Division of Nueva Ecija
PARTICULAR Amount
TO LIQUIDATE DOWNLOADED MOOE FOR THE MONTH OF JUNE 2017 AMOUNTING TO

TWENTY NINE THOUSAND SEVEN HUNDRED FIFTY SEVEN & 01/100 PESOS ONLY 29,757.01
TOTAL AMOUNT SPENT

29,757.01
BALANCE OF PREVIOUS CASH ADVANCE
4,737.01
AMOUNT OF CASH ADVANCE PER DV NO.
26,020.00
BALANCE OF CASH ADVANCE 1000 DTD. 6/6/2017
1,000.00
A Certified: Correctness of the B Certified: Purpose of travel/cash C Certified: Supporting documents
above data: advance duly accomplished: complete and proper:
Pre-Audited by:
HERMOGENES N. CAMANGEG
Claimant Immediate Supervisor ADAS III
Designation: SP II
School: MARAH M. PACSON
Head, Accounting Unit
MOOE ATTACHMENTS
Please accomplish and arrange in order.
Travel Expenses Purchased supplies and m

1. Picture of Check 1. Picture of Check
2. Disbursement Voucher 2. Disbursement Voucher
3. Travel Order 3. Invoice/OR/DR/RER
4. Duly Approved Itinerary of travel 4. Pictures***
5. Certificate of travel completed 5. IAR
6. Certificate of appearance 6. Purchase Order (P.O.)
7. Attach Memorandum Req.(if) training/Seminar attaended 7. Abstract of Open Canvass
8. For rentals of van, Acknowledgment receipt 8. Request for Quotations (R
9. Purchase Request (P.R.)
Training Expenses 10. Property Acknowledgme
1. Picture of Check
2. Disbursement Voucher General Services/ Securit
3. Memorandum 1. Picture of Check
4. Official receipt 2. Disbursement Voucher
5.Certificate of appearance 3. Contract of service
6. Photocopy of Certificate of Participation 4. Duly approved DTR
5. Accomplishment report
Water/Electricity/Internet Expenses
1. Picture of Check Tax remittances
2. Disbursement Voucher (1 for supplier, 1 for reimbursing personnel) 1. Disbursement Vou
3. Statement of Account/Bill 2.Picture of Check
4. Official Receipt 3.Deposit slip
6. BIR form 2306 4.BIR form 1600
7. BIR form 2307 5.BIR form 1601-E
6.Alphalist of 1601-E
Repairs & Maintenance

1. Picture of Check
2. Disbursement Voucher
3. Invoice/OR/DR
4. Pictures with Caption***
(before, during, after)
5. IAR
6. Purchase Order (P.O.)
7. Abstract of Open Canvass
8. Request for Quotations (RFQs)
9. Program of works
11. Labor Contract
12. Labor Payroll and
Acknowledgment Receipt
*for repairs 10,000 and above
1.Letter request duly approved by the Schools Division Superintendent
*for repairs with donated materials
1. Certificate or copy of the received donated materials/Proof of donation/Resolution
*** Inspectors should be included in the pictures (while cheking goods/evaluating output of services)
For the purpose of actual validation of purchases
Purchased supplies and materials

1. Picture of Check
2. Disbursement Voucher OK
3. Invoice/OR/DR/RER OK
4. Pictures***
6. Purchase Order (P.O.)

7. Abstract of Open Canvass
8. Request for Quotations (RFQs)
10. Property Acknowledgment Receipt (PAR) if equipment; Inventory Custodian Slip if semi-expendable
General Services/ Security/ Janitorial services

1. Picture of Check
2. Disbursement Voucher
3. Contract of service
4. Duly approved DTR
5. Accomplishment report
Tax remittances
1. Disbursement Voucher (1 for supplier, 1 for reimbursing personnel)
2.Picture of Check
3.Deposit slip
4.BIR form 1600
5.BIR form 1601-E
6.Alphalist of 1601-E
Account Codes for Disbursement Vouchers
5020101000 Travel Expenses
5020201000 Training Expenses
5020301000 Office Supplies Expenses
5020307000 Drugs, Medicine Expenses
5020399000 Other Supplies Expenses
5020401000 Water Expenses
5020402000 Electricity Expenses
5020503000 Internet Subscription Expenses
5021299000 Other Gen.Services
5021203000 Security Services
5021202000 Janitorial Services
5021304002 Rep&Maintenance-School Building
5021299000 Rep&Maintenance-IT Equipment
5021307000 Rep&Main-Furniture & Fixtures
5021304099 Rep&Main-Other Structures
5021502000 Fidelity Bond Premium
5029999002 Other MOOE
1990104000 Advances for Operating Expenses

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PURCHASE REQUEST

Entity Name: Department of Education Fund Cluster: __________

Responsibility Center Code : __________________

1 PC. TARPAULIN 1 336.00 336.00

Requested by: Approved by:

CONVERSION INTEGRATED SCHOOL - SECONDARY

REQUEST FOR QUOTATION

JOEY PASCUA EMERLINDA R. VILLA

PROCUREMENT TERMS AND CONDITIONS

Delivery Period: 7/13/2017

4R MACAPAGAL ADVERTISING & FURNITURE

Conversion Integrated School - Secondary

REQUEST FOR QUOTATION

JOEY PASCUA EMERLINDA R. VILLA

PROCUREMENT TERMS AND CONDITIONS

Delivery Period: 7/13/2017

FERNANDO C. PAYAWAL ADVERTISING

Conversion Integrated School - Secondary

REQUEST FOR QUOTATION

JOEY PASCUA EMERLINDA R. VILLA

PROCUREMENT TERMS AND CONDITIONS

Delivery Period: 7/13/2017

ABSTRACT OF CANVASS BID

1 PC. TARPAULIN 336.00 336.00 355.00 355.00 385.00 385.00

TOTAL TOTAL 336.00 355.00 385.00

Recommending award to 4R MACAPAGAL Advertising & Furniture

MARITES T. BALDEREZ DONDY PASCUA EMERLINDA R. VILLA

Place of Delivery : Conversion Integrated School - Secondary Delivery Term : Pick up

1 PC. TARPAULIN 1 336.00 336.00

(Total Amount in Words) THREE HUNDRED THIRTY SIX PESOS ONLY

Conforme: Very truly yours,

4R MACAPAGAL ADVERTISING & FURNITURE EMERLINDA R. VILLA

7/13/17 School Head

Fund Cluster : ___________________________________ ORS/BURS No. : ______________________

INSPECTION AND ACCEPTANCE REPORT

Supplier : 4R MACAPAGAL ADVERTISING & FURNITURE IAR No. : _______________

Inspected, verified and found in / Complete

JENNIFER J. PASCUA DONDY PASCUA

Fund Cluster : 01101101

Mode of MDS Check / Commercial Check ADA Others (Please specify)

Particulars Responsibility Center MFO/PAP Amount

Payment for Tarpaulin for Nutrition Month

GROSS AMOUNT P 336.00

Tax Withheld (Vat Reg.)

Amount Due P 318.00

E. Receipt of Payment JEV No.

8 Registered Address 9 Registered Address

Part II Details of Income Payment and Tax Withheld

Total 336.00 15.00

Payor/Payor's Authorized Representative Payee/Payee's Authorized Representative

1 For the Period

5 Foreign Address 5A Zip Code

Total 336.00 3.00

Payee/Payee's Authorized Representative Date Signed

LBP ACCOUNT FORWARDED BALANCE 4,737.01

Payment of tax withheld (BIR

Payment of tax withheld (BIR

TOTAL 29,757.01 1,708.16 30,757.01 29,757.01 1,000.00

Certified Correct: Certified Correct: Approved:

Fund Cluster : _____________ ORS/BURS No. :