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Appendix 48
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PETTY CASH VOUCHERNo. : __________________
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Entity Name : _____________________________
Date : _________________
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Fund Cluster: _____________________________
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Payee/Office : ____________________________Responsibility Center Code:
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Address : ______________________________________________________
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I. To be filled out upon request
II. To be filled out upon liquidation
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ParticularsAmount
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Total Amount Granted______________
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Total Amount Paid per
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OR/Invoice No. _____________________
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Amount Refunded/ (Reimbursed)
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Requested by:
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Received Refund
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__________________________
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 Signature over Printed NameReimbursement Paid
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Name of Requestor
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Approved by:
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____________________________________________________
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 Signature over Printed Name Signature over Printed Name
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Name of Immediate SupervisorPetty Cash Custodian
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Paid by:
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Liquidation Submitted
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__________________________
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 Signature over Printed NameReimbursement Received by:
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Petty Cash Custodian
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Cash Received by:
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____________________________________________________
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 Signature over Printed Name Signature over Printed Name
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PayeePayee
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Date: _______________Date: _______________
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