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46Appendix 13
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REPORT OF ADVICE TO DEBIT ACCOUNT ISSUED
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Period Covered: ________________
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Entity Name : ____________________________________________
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Fund Cluster : ___________________________________________Report No.: ____________________________
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Bank Name/Account No. : __________________________________Sheet No.: ____________________________
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ADADV/Payroll No. ORS/BURS No.Responsibility Center CodePayee UACS Object CodeNature of PaymentAmount
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DateSerial No.
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CERTIFICATION
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I hereby certify on my official oath that the above is a true statement of all ADAs issued by me during
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the period stated above for which ADA Nos. ____________ to ___________ inclusive, were actually issued by me in the amounts shown thereon.
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______________________________________________
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Name and Signature of Disbursing Officer/Cashier
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________________________________________________________
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Official DesignationDate
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