Report of Checks Issued Tes - 4 Form Date: - HEI Name: Report No.: - Sheet No.

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REPORT OF CHECKS ISSUED

TES - 4 FORM
Date: ______________

HEI Name:
Report No.: ___________________
Sheet No.: ____________________
Check Issued
DV/Payroll No. Payee Nature/Type of Payment Amount
Date Check No.

TOTAL -
CERTIFICATION
I hereby certify on my official oath that this Report of Checks Issued in one (1) sheet is a full, true and
correct statement of all checks issued by me during the period stated above for which Check Nos. _______
inclusive, were actually issued by me in payment for obligations shown in the attached disbursement
vouchers/payroll.

(Signature above printed name)


Cashier
Date Signed: _________________

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