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98Appendix 35
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REPORT OF CHECKS 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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CheckDV/Payroll No. ORS/BURS No.Responsibility Center CodePayee UACS Object CodeNature of PaymentAmount
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DateSerial No.
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C E R T I F I C A T I O N
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 I hereby certify on my official oath that this Report of Checks Issued in _________ sheet(s) is a full, true and correct
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statement of all checks issued by me during the period stated above for which Check Nos. ___________ to _____________ inclusive,
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were actually issued by me in payment for obligations shown in the attached disbursement vouchers/payroll.
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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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