ABCDEFGHIJKLMNOPQRSTUVWXYZ
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CLAIM FOR OVERTIME / EXTRA SERVICES RENDERED
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for the month of MONTH YEAR
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Type of Claim:Overtime / ES PayCOC
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C H E C K L I S TR O U T I N G S L I P
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SUPPORTING DOCUMENTS
(to be accomplished by concerned staff)		To be accomplished by PAS
Received at PAS
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Name:
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Statement of Overtime Services Rendered
Attached
Date/Time:
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Dates:
Remarks
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Remarks:
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Annex C (Statement of Specific Work Accomplished)Attached
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Dates:
Remarks
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Copy of Approved Daily Time RecordAttached
Reviewed by PAS Focal Person
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Month:
Remarks
Name:
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Copy of Approved Special Order
Attached
Date/Time:
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Dates:
Remarks
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Others, if applicable:
Complete
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Copy of Approved Locator Slip
Attached
Incomplete
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Dates:
Remarks
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Copy of Signed Activity Log (ICS Form 214)
Attached
Deadline of Compliance of Lackings:
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Dates:
Remarks
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Copy of Attendance Sheets / Logbook
Attached
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Dates:
Remarks
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Certificate of Early Duty
AttachedReceived at Concerned Office for Compliance of Lackings
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Dates:
Remarks
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Copy of Trip Ticket
Attached
Name:
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Dates:
Remarks
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Certificate of Appearance
Attached
Date/Time:
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Dates:
Remarks
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Copy of Processed Itinerary of Travel
Attached
Remarks:
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Dates:
Remarks
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Copy of Approved Schedule of Duty
Attached
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Dates:
Remarks
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Additional Notes/Remarks, if any
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LACKINGS (To be accomplished by PAS)
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Complied
Date/Remarks:
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Complied
Date/Remarks:
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Complied
Date/Remarks:
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Complied
Date/Remarks:
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Complied
Date/Remarks:
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Certified by:
Verified by PAS staff:
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I certify that the supporting documents attached to
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the claim are COMPLETE, VALID, PROPER and LEGAL.
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SIGNATURE OVER PRINTED NAME OF CLAIMANT
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Position, Office
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PAGE 1 of 1
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DSWD Field Office 1, Quezon Avenue, City of San Fernando, La Union, Philippines 2500
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Website: fo1.dswd.gov.ph Tel Nos.: (072) 687-8000
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