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