Republic of the Philippines

PROVINCIAL GOVERNMENT OF QUIRINO COMMUNITY UNITED in

ACTION
Cabarroguis, Quirino
DISBURSEMENT VOUCHER No.
Mode of
Check Cash Others Date:
Payment
TIN/
Employee Obligation
Payee No. Request No.
Responsibility Center

Address
Function/Program/Project

EXPLANATION AMOUNT

TOTAL _
_
_
A. Certified as to: B. Certified as to:
Funds availability Cash Availability
Completeness and propriety of supporting
Signature/
documents. Signature /
Printed EUGENIO D. Date Printe Date
d
Name MORALES Name FE B. MANGACCAT
Position Provincial Accountant Posit Provincial Treasurer
ion
C. Approved for Payment D. Received Payment
Signature/ Check No. Bank Name Date
Printed Date Signat Date
ure /
Name JUNIE E. CUA Printed Name
Position Provincial Governor OR/Other Documents
JOURNAL ENTRY
Account No: Responsibility No:
Center:
ACCOUNTING ENTRIES
 Accoun AMOUNT
Accounts and Explanation PR
t Code Debit Credit

COA ACTION:
 Republic of the Philippines
PROVINCIAL GOVERNMENT OF QUIRINO
Cabarroguis

OBLIGATION REQUEST No.

Payee JIO ENTERPRISES Date:
Office
Address SANTIAGO CITY
Responsibility Particulars F/P/P Account
Center Code

4421 Purchase Request of Laboratory

Supplies for
Qurino Provincial Hospital, in the 760 D
total amount of---

TOTAL
A Certified as to: Certified as to
B
Charging to appropriation/allotmen, necessary, lawful
and under my direct supervision
Supporting documents valid, proper and legal.

Signature Signature

Printed Name TAGUMPAY A. FELISMINO,MD.,MHA Printed Na

Position Provincial Health Officer II Position
Date Date
QUIRINO COMMUNITY UNITED in ACTION

Amount

Php 26,850.00

Php26,850.00
Certified as to
Availability of Appropriation/Allotment
Obligation of Allotment for the purpose
as indicated.

Signature

ARTURO A. QUEBRAL
Provincial Budget Officer
 Annex 33

PURCHASE ORDER COMMUNITY UNITED in ACTION

PROVINCIAL GOVERNMENT OF QUIRINO

Supplier: P.O. No:

Address: Date:
TIN No. P.R. No/s Mode of Procurement:

Sir/Madam:
Please furnish this Office the following articles subject to the terms and conditions contained herein:

Place of Delivery: ________________________________ Delivery Term: ________________

Date of Delivery: _______________________________ Payment Term: ________________
Item Unit Quantity Description Unit Cost Amount

(Total Amount in Words) Php -

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.
Very truly yours,

Conforme:
JUNIE E. CUA
Provincial Governor

________________________
_________________
Dealer/
Supplier
Date: PGSO Posted by:
(Signature
over printed name)
 ________________________
_________________
Dealer/
Supplier
(Signature
(In case
overof printed
Negotiated Purch Requesitioning Office/ Funds Available:
name)
pursuant to Sec. 369(a) of Amount:
RA 7160, this portion must be
accomplished).
Approved to be purchased
thru negotiated purchase per
Sangguniang Res. No.______ Authorized Official EUGENIO D. MORALES
Provincial Accountant
Certified correct:
___________________________________
Secretary to the Sangguniang Panlalawigan
Copy Distribution:
ORIGINAL COPY…………Attached to Vou BLUE COPY………Supplier/Sealer Copy
GREEN COPY…………….PGSO File yellow copy………..Governor's Office
PINK COPY……………….COA File
cma 11
 NC MULTISALES
Aurora West, Diffun, Quirino Shopping
1611

PGSO-PEO Full delivery

With in 15 days upon receipt hereof

1 pails 1 Flatwall Enamel, White Boysen 2,580.00 2,580.00

2 pails 1 Semigloss Latex White Boysen 2,760.00 2,760.00
3 ltrs 2 NTC Lamp Black 150.00 300.00
4 ltrs 2 NTC Thalo Blue 180.00 360.00
5 gals 2 Paint Thinner 280.00 560.00
6 pcs 3 paint Brush 4" 96.00 288.00
7 sets 2 Paint Roller w/ tray 180.00 360.00
-x-x-x-x-x-x-x-z-x-x-x- -
-
-
-
-
-
-

SEVEN HUNDRED TWO HUNDRED EIGHT P7,208.00

PESOS ONLY

NC MULTISALES
 Republic of the Philippines
PROVINCIAL GOVERNMENT OF QUIRINO COMMUNITY UNITED in ACTION
Cabarroguis

BIDS AND AWARDS COMMITTEE

__________________________
Date

Gentlemen:
Please qoute your price in a sealed envelope for the article/s listed hereunder to be opened on
_____________________ at _____________________________ in this office.

ITEM NO. QTTY. UNIT A R T I C L E/S UNIT PRICE

I HEREBY CERTIFY that the prices indicated under column is correct.

I FURTHER CERTIFY that if we secure a waiver for or refusal of all or any portion of government taxes, fees,
impost or duties, proper refund thereof shall be made in favor of the Provincial government of Quirino.
WITNESS TO CANVASS: _______________________________
Dealer/Supplier/Contractor

Bac Secretariat Representative

 Republic of the Philippines
PROVINCIAL GOVERNMENT OF QUIRINO COMMUNITY UNITED in ACTION

Cabarroguis

ACCEPTANCE & INSPECTION REPORT

Provincial General Services Office

SupplierRETA DRUG AIR No._____________________________

P. O. No. Invoice No.____
Requisitioning Office/Dept. PEO
Item Unit Description Unit Total Quantity
No. Price Amount
1 vls Metronidazole 31.50 6,300.00 200
2 vls Cefuroxime 750mg 54.00 16,200.00 300
3 amps Ranitidine 150mg/2ml 23.50 7,050.00 300
4 amps Ketorolac 50g/2ml 128.00 19,200.00 150
5 nebs Budisonide 250mg 72.00 21,600.00 300
6 amps Gentamicin 40mg/2ml 17.00 3,400.00 200
7 nebs Comvibent neb 59.00 17,700.00 300
8 bxs Mefenamic acid 500mg 77.00 770.00 10
9 bxs Amoxicillin 500mg 249.00 2,490.00 10
10 bxs Vitamin B complex tablet 149.00 1,490.00 10
11 pcs Paracetamol 18.50 3,700.00 200
12 amps Atropine Sulfate 11.50 575.00 50
13 amps Tranexamic acid 64.50 6,450.00 100
14 amps Dopamine 81.00 4,050.00 50
15 amps Metoclopramide 11.50 1,150.00 100
16 amps Hyoscine n butyl 27.50 2,750.00 100
17 amps Clonidine am 159.00 7,950.00 50
18 bxs Clonidine tab 1,400.00 2,800.00 2
19 amps Dilantin 1,400.00 14,000.00 10
20 vls Omeprazole 220.00 11,000.00 50
21 bxs Cefalexin 500mg 419.00 4,190.00 10
22 vls Hydrocortisone 100mg 39.00 3,900.00 100
23 vls Hydrocortisone 250mg 58.50 5,850.00 100
24 amps Diphenhydramine amp 159.00 15,900.00 100
25 vls Ceftriaxone 1g/ w/ diluent 54.00 10,800.00 200
26 amps Tramadol 43.00 4,300.00 100
27 vls Ampicillin 500mg/vl 10.50 1,050.00 100
28 vls Ampicillin 250mg/vl 14.50 1,450.00 100
29 amps Terbutaline 500mg IV 75.00 7,500.00 100
30 amps Citicoline 249.00 12,450.00 50
31 amps Nicardipine 1,200.00 24,000.00 20
32 vls Oxacillin 75.00 3,750.00 50
INSPECTION ACCEPTANCE

Date Inspected: _______________________ Date Received:________________

Inspected, verified and found OK as to Complete
quantity and specification. Partial

Inspector/Verifier Property Officer

 Republic of the Philippines
COMMUNITY UNITED in ACTION
PROVINCIAL GOVERNMENT OF QUIRINO
Cabarroguis
REQUISITION AND ISSUE SLIP
Provincial Health Office
Responsibility Center
Division:___PHO__________________________
Office:
Requisition Issuance
Stock No. Unit Description Quantity Unit Total Amount
Price

Purpose
_______________________________________________________________________________________________
Requested by: Approved by: Issued by: Received By:
 A. WITH APPROVED PO, ACCEPTANCE AND RIS.
NO. Invoice No. DATE AMOUNT PO No. DATE AIR NO. DATE PURPOSE

3 4112 9/13/2007 5,500.00 2007-09-386 9/12/2007 516 9/13/2007 For SBK 390
5 4066 9/3/2007 25,400.00 2007-08-373 8/31/2007 488 9/3/2007 For H3-6241
6 4061 6/7/2007 15,720.00 2007-06-249 6/4/2007 335 6/7/2007 do
10 4114 9/11/2007 11,000.00 2007-09-382 9/7/2007 515 3/11/2007 do
12 4048 4/24/2007 46,400.00 2007-04-192 4/20/2007 279 4/24/2007 For H3-6242
13 4063 6/25/2007 25,220.00 2007-06-278 6/19/2007 481 6/25/2007 do
15 4137 6/28/2007 60,300.00 2007-06-294 6/26/2007 542 6/28/2007 For H3-6243
16 4046 7/2/2007 21,600.00 2007-06-289 6/25/2007 478 7/2/2007 do
17 4134 6/25/2008 18,800.00 2007-06-277 6/19/2007 557 6/25/2007 do
20 4045 6/12/2007 25,000.00 2007-04-203 4/26/2007 485 6/12/2007 For SBS 588
22 1752 7/4/2007 5,500.00 2007-06-293 6/26/2007 509 7/4/2007 do
23 4065 5/7/2007 23,100.00 2007-04-202 4/26/2007 460 5/7/2007 For SBS 640
24 3991 4/16/2007 24,500.00 2007-04-179 4/12/2007 281 4/16/2007 For PL-1413
25 4113 9/28/2007 22,000.00 2007-09-397 9/27/2007 527 9/28/2007 do
27 4055 7/2/2007 40,300.00 2007-06-292 6/26/2007 484 7/2/2007 For roadGrader NI2031
29 4106 8/27/2007 16,500.00 2007-08-363 8/25/2007 518 8/27/2007 do
31 4072 6-25-076 21,700.00 2007-06-287 6/22/2007 468 6/25/2007 do
32 4105 6/28/2007 46,680.00 2007-06-286 6/22/2007 464 6/28/2007 For NI 2217

TOTAL 455,220.00

B.
B. PO FOR APPROVAL BUT WITH ACCEPTANCE AND RIS

NO. INVOICE NO. DATE AMOUNT P.O. NO. DATE AIR NO. DATE PURPOSE

4 4049 4/24/2007 21,000.00 2007-04-191 4/20/2007 280 4/24/2007 For H3-6241

7 4064 7/2/2007 15,700.00 2007-06-291 6/26/2007 493 7/2/2007 do
18 4095 6/12/2007 11,000.00 2007-06-251 6/6/2007 473 6/12/2007 For SBF-955
33 4025 5/15/2007 17,800.00 2007-05-208 5/9/2007 282 5/15/2007 For Roadgrader NI-2217
T OT A L 36,700.00

T OT A L 65,500.00
C. PO and ACCEPTANCE FOR APPROVAL BUT WITH RIS
NO. Invoice No. DATE AMOUNT PO NO. DATE AIR No. DATE PURPOSE

1 4145 56,410.00 2007-10-418 10/12/2007 For H3-6240

4146 SBK-390
2 4147 15,800.00 2007-10-428 10/22/2007 do
8 4194 14,750.00 For H36241
19 4104 23,200.00 For SBS-588
21 3783 10,800.00 2007-10-371 8/31/2007 do
30 4078 14,800.00 for Roadgrader NI-2031
34 4075 27,400.00 For SBK-399
TOTAL 163,160.00
zenaida c dayawon
 PURCHASE REQUEST
PROVINCIAL GOVERNMENT OF QUIRINO COMMUNITY UNITED in ACTION

LGU
PR No.:_________________________ Date:_________________
Department PHO O.S. No.:________________________Date:_________________
Section___ Mangandingay,Cabarroguis RIS No.:_________________________Date:_________________
Unit of Stock Estimated Estimated
Quantity Issue Item Description No. Unit Cost Cost

190 Pcs NBS KITS 1 550.00 104,500.00

Charge to MHCN

TOTAL 104,500.00
For Birthing Clinic, RHU's & Hospital used.
Purpose:

"THE PROCUREMENT OF THE ABOVE LISTED GOODS TROUGH_____________________________ AS

PROVIDED FOR IN THE IMPLEMENTING RULES AND REGULATION OF REPUBLIC ACT NO. 9184 IS HEREBY
APPROVED"
Requested by; Approved by:
Signature:

Printed Name:
ROGER T. BAGUIOEN,MD.,DPBR,MHcA JUNIE E. CUA
Designation Chief of Hospital III / PHO-OIC Provincial Governor
 Republic of the Philippines
COMMUNITY UNITED in ACTION
PROVINCIAL GOVERNMENT OF QUIRINO

Cabarrouis

PROPERTY ACKNOWLEDGEMENT RECEIPT

Barangay:Dumanisi City/Municipality: Diffun
Province: Q U I R I N O PAR NO:

Quantity Unit Description Property Date

Unit Price NO Acquired

4 units Knapsack Sprayer 2,400.00

-x-x-x-x-x-x-x-x-z-x-x-x-x

DEALER: NC MULTISALES
Fund: 8918.4L-878
PR# 1189
PO# 1235
AIR # ______________
RIS# ______________
OB R# 181108 153

Received by: Issued by:

______________________________ DR. NOEL B. MARTINEZ

Signature Over Printed Name Signature Over Printed Name
Recipient/User Prov'l. Gen. Services Officer
Position

_____________________________ _____________________________
Date Date
Y UNITED in ACTION

EIPT

Cost

9,600.00

9,600.00
 Republic of the Philippines
COMMUNITY UNITED in ACTION
PROVINCIAL GOVERNMENT OF QUIRINO
Cabarroguis

ACKNOWLEDGEMENT RECEIPT FOR EQUIPMENT

Provincial General Services Office
ARE#
Division: Purchase Order: RIS No: Date: _________
Office: PHO No. 1229 P.R. No _ 1582 Date: 08-5-11
Requisition Issuance
Stock No Unit Description Quantity Unit Price

1 unit Intel Core 2 Duo E7500 2.53 Ghz 1 33,000.00

Mainboard Built in VSL
1 gb ddr3 Kingston
500gb SATA
DVD Writer
ATX Casing w/ 500w PSU
15.6" LED/LCD Monitor
A4tech USB Jeyboard
A4tech USB Optical Mouse
AVR 500 watts
Multimedia Speaker
Epson LX300+11
Computer Table
Computer Chair
-x-x-x-x-x-z-x-x-x-

Dealer: AURORA COMPUTER CENTER

Fund: TRUST FUND
PR# 1582
PO# 1229
AIR # ______________
RIS#
OB R # TRUST FUND
Purpose: For pho USE (Dialysis Dept.)
________________________________________________________________________________________________
Received by Received From
Signature
Printed Name NOEL B. MARTINEZ,Ph.D.
Designation Provincial General Services Officer
Date
UNITY UNITED in ACTION

________

ssuance
Total Amount

33,000.00

33,000.00

________________

RTINEZ,Ph.D.
al Services Officer
 Republic of the Philippines
COMMUNITY UNITED in ACTION

PROVINCIAL GOVERNMENT OF QUIRINO

Cabarroguis
ABSTRACT OF LOCAL QUOTATION FOR FURNISHING AND DELIVERING SPAREPARTS AS PER PURCHASE NO.
_1616 DATED 08-09-11 FOR USE OF PPDO UMK 969

ITEM NO. QTTY. UNIT ARTICLE DEALERS AND THEIR PRICES

AV MENDOZA UNIBEST
ENTERPRISES
1 1 set Aircon reconditioning 2,000.00 2,020.00
2 4 set Door Upholstery 500.00 505.00
3 6 pcs Spray Noozle 700.00 707.00
4 7 ltrs Motor Oil #40 222.00 224.22
5 2 pcs Fuel Filter 840.00 848.40
6 1 ltrs Brake Fluid 220.00 222.20
7 1 pcs Oil Filter 550.00 555.50
8 1 pcs Battery 3SM 6500.00 6,565.00
9 1 pcs Centerlink tie rod end 6500.00 6,565.00
10 1 pcs Radiator hose 520.00 525.20
11 1 pcs Rear shock absorber 2500.00 2,525.00
-x-x-x-x-x-x-x-x-z-x-x-x-

28,224.00
Opened at ___________ A.M on ________________________________________ 200_____.
We hereby certify that we canvassed the prices of the above articles and that the prices are true and correct as
quoted by the dealers

DENCIO A. PAGBILAO
BAC Secretariat Representative BAC Secretariat Head

The Provincial Bids and Awards Committee has decided to award the procurement of the aboved-mentioned
supplies to
toAV MENDOZA
ISABELA ENTERPRISES
ZIRCON ENTERPRISEShaving offered
having the lowest
quoted prices in
the lowest the canvass
price made bymade
in the canvass the canvass
by thecom.
canvass
committee.

DENCIO A. PAGBILAO LOLINDA PAGULAYAN

Head of the Requisitioning Office Local Treasury Operations Officer IV
(Memebr

FE B. MANGACCAT IRENEO N. BENAVIDEZ

Provincial Treasurer) Provincial Engineer
(Member) ARTURO A. QUEBRAL (Member)
Provincial Budget Officer
(Chairman)P 195,000.00
 MMUNITY UNITED in ACTION

PER PURCHASE NO.

D THEIR PRICES
F. MIANA

2,040.20 2,000.00
510.05 2,000.00
714.07 4,200.00
226.46 1,554.00
856.88 1,680.00
224.42 220.00
561.06 550.00
6,630.65 6,500.00
6,630.65 6,500.00
530.45 520.00
2,550.25 2,500.00
28,224.00

are true and correct as

GBILAO

f the aboved-mentioned
ymade
the canvass
by thecom.
canvass

AGULAYAN
perations Officer IV

BENAVIDEZ
l Engineer
 Republic of the Philippines
COMMUNITY UNITED in
PROVINCIAL GOVERNMENT OF QUIRINO ACTION
Cabarroguis, Quirino
DISBURSEMENT VOUCHER No.
Mode of
Check Cash Others Date:
Payment
TIN/Employee No. Obligation Request
Payee BIR - QUIRINO No.
Responsibility Center
Address
San Marcos, Cab. Qno. Function/Program/Project

EXPLANATION AMOUNT

To remittance of taxes withheld from NC MULTISALES for the payment of 1,874.36

materials for the construction of collapsible shed use as per supporting papers
hereto attached in the amount of . . . . . .

Gross Amount 46,859.00

Gross*3% 1,405.77
Gross*1% 468.59

TOTAL P1,874.36
A. Certified as to: B. Certified as to:
Funds availability Cash Availability
Completeness and propriety of supporting documents.
Signature/ Signature /
Printed Date Printed Date
EUGENIO D. MORALES FE B. MANGACCAT
Name Name
Position Provincial Accountant Position Provincial Treasurer
C. Approved for Payment D. Received Payment
Signature/ Check No. Bank Name Date
Printed Date Signature / Date
Name JUNIE E. CUA Printed Name

Position Provincial Governor OR/Other Documents

JOURNAL ENTRY
Account No: Responsibility Center: No:
ACCOUNTING ENTRIES
AMOUNT
Accounts and Explanation Account Code PR
Debit Credit

COA ACTION:
 Republic of the Philippines
PROVINCIAL GOVERNMENT OF QUIRINO COMMUNITY UNITED in ACTION
Cabarroguis

OBLIGATION REQUEST No.

Payee AV MENDOZA ENTERPRISES Date:
Office PGSO
Address Santiago City
Responsibility Particulars F/P/P Account Amount
Center Code

PR of spareparts for SFA P 14,660.00

622

TOTAL P 14,660.00
A Certified as to: Certified as to
B
Charging to appropriation/al Availability of Appropriation/Allotment
and under my direct supervision Obligation of Allotment for the purpose
Supporting documents valid, proper and legal. as indicated.

Signature Signature
Printed Name FE B. MANGACCAT Printed Name ARTURO A. QUEBRAL
Position Provincial Treasurer Position Provincial Budget Officer
Date Date
 Republic of the Philippines
COMMUNITY UNITED in ACTION
PROVINCIAL GOVERNMENT OF QUIRINO

DISBURSEMENT VOUCHER No.

Mode of payment
Check Others Date:
TIN/Employee No. Obligation Request No.
Payee
GLENDA S. BETGUEN Responsibility Center
Address
CABARROGUIS, QUIRINO Function/Program/Project

EXPLANATION AMOUNT

To reimbursement of Internet expenses by QPH Globe Account No.

851127025 and other supporting papers attached in the total amount
of………… Php 3,165.00

A. Certified as to: B. Certified as to:

Funds availability Cash Availability
Completeness and propriety of supporting documents.
Signature/ Date Signature / Date
Printed Printed
Name CECILIA B. VALDEZ, CPA, MSBA Name FE B. MANGACCAT
Position Provincial Accountant Positi Provincial Treasurer
on
C. Approved for Payment D. Received Payment
Signature/ Date Check No. Bank Name Date
Printed Signatu Date
re /
Name Printed
JUNIE E. CUA Name

Position Provincial Governor OR/Other Documents

JOURNAL ENTRY
Account No: No:
Account ACCOUNTING ENTRIES
s and AMOUNT
Explana Account Code PR
tion Debit

COA ACTION:
 Republic of the Philippines
PROVINCIAL GOVERNMENT OF QUIRINO
Cabarroguis, Quirino

TRACKING SLIP
Instructions: This Document Tracking Slip (DTS) should be attached to all documents,
received, instituted, or is to be instituted by the Provincial Government so as to be able to
identify and thereafter cause key innovations centered on productivity, effectivity and quality
of work. Rest assured, no prejudice shall be incurred by anyone by reason of this study,
except, that is, where it be later discovered that an entry or entries herein be a product or is
tainted with falsehood or malice.

Source/Origin: Nature of Document: Doc. No.:

PHO Purchase Request

Deadline:

Title/Subject: Dfor PESU used.

Attachments: (Use back portion or attach annex or listing down attached documents if necessary)

RECEIVED/ACTED UPON BY IMPORTANT: Pls. be advised that such data set forth is deemed
under oath and that any falsehood shall be accordingly prosecuted
administratively and criminally.

Name/Position Signature Date/Time Action Taken/Comments

Jovanie L. Amoy Prepared PR
Roger T. Baguioen Signed PR
 Republic of the Philippines
Provincial Government of Quirino
Cabarroguis, Quirino
 Republic of the Philippines
COMMUNITY UNITED in ACTION
PROVINCIAL GOVERNMENT OF QUIRINO
Cabarroguis
No.
LIQUIDATION REPORT Date:
Province of Quirino Responsibility Center

PARTICULARS AMOUNT

To liquidation cash advance for the Provincial Health Office Quality

Management Orientation Workshop and Capacity Building on
Php 56,750.00
September 20-23,2018 @ Treasures of Bolinao, Pagasinan and Fidel
Salt Farm, with the total amount of..

Total Amount Spent : 66,750.00

AMOUNT OF CASH ADVANCE PER DV NO. _________ DATED__________ 56,750.00
AMOUNT REFUNDED PER OR NO. _________________ DATED__________
AMOUNT TO BE REIMBURSED: ____________________________________ 10,000.00
Submitted by: Received by:

MILA J. VILLAR, MD, MPH CECILIA B. VALDEZ,CPA,MSBA

Provincial Accountant
Provincial Health Officer II Date : __________________________

OPAC-009-0