Appendix 40

CASH DISBURSEMENTS RECORD

Entity Name : __________________________

Fund Cluster : __________________________ Sheet No. : _________________

___________________ ________________________________ ________________

Accountable Officer Official Designation Station

Cash
Cash
UACS Object Advance
Date Payee Nature of Payment Disbursements Advance
ADA/Check/ Code Received/
Balance
DV/Payroll/R (Refunded)
eference No.

CERTIFICATION

I hereby certify on my official oath that the foregoing is a correct and complete record of all cash
disbursements had by me in my capacity as ______(Designation)____ of (Name of Agency) during
the period from _______________ to _______________,inclusive, as indicated in the corresponding columns.

_______________________________
Name and Signature of Disbursing Officer
________________
Date

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