In

settlem
ent of
the
followin
g
amount:
Payment due:

Form of
Payment:
Cash
Check

Name of Busimess
Address:

Contact Number:

OFFICIAL Receipt
Date:
Received from
with TIN and address at

engaged in the business style of
the sum of

pesos in partial/full payment of
.

Cashier/Authorized Representative
Signature over printed
name