Annex "E"

General Form No. 74(A) Republic of the Philippines

COMMISSION ON AUDIT

REPORT OF CASH EXAMINATION

Name of Accountable Officer:
Agency: Station:
Maximum Cash Accountability: ₱ Amount of Bond: ₱ Risk No.: Effective Date:
Auditor/Examiner: Official Designation:

A. CASH PRODUCTION NOTICE

TO: Accountable Officer: Position/Designation: Date:

DEMAND, is hereby made that you produce all your cash, checks, money orders, cash items, paid vouchers, and/or unused accountable forms,
etc., for which you are officially accountable as ___________________ of the __________________________ and any fund, checks, and/or cash items in
your possession held by you for deposit and safekeeping.

NOTED AND Accountable Officer's Signature: Date: Auditor/Examiner's Signature:

COMPLIED
WITH
B. CASH COUNT
INVENTORY OF CASH ON HAND INVENTORY OF CASH ITEMS (Include checks, money orders, etc.)
Paper and Coins: Amount
Particulars
No. of Presented Allowed Disallowed
Denomination Pcs. Amount
P 1,000.00
500.00 -
100.00 -
20.00 -
0.25 -
0.05 -

TOTAL
Total, As Presented Total ₱
TOTAL INVENTORY OF CASH AND/OR ALLOWED CASH ITEMS (TO D)

C. INVENTORY OF UNUSED ACCOUNTABLE FORMS

With Money Value Without Money Value
Inclusiv
e Serial Denomin
Name of Form Qty. No. ation Amount Name of Form Qty. Inc. Serial No.
A/F NO. 51 - Official Receipts

Total 0
C E R T I F I C A T I ON
I HEREBY CERTIFY on my official oath: (1) That upon demand by the Auditor/Examiner I produced all my cash, checks, money orders, cash
items, paid vouchers, unused accountable forms, etc., for which I am officially accountable; (2) That the inventory of such cash items and unused
accountable forms in my possession and produced to the Auditor/Examiner at the time of cash count today, _________________ is correctly stated above
and is broken down as follows:
Cash and/or cash items ……………………………….. 0.00
Unused accountable forms with money value …………
Unused accountable forms without money value ……..

of which none was disallowed by the Auditor/Examiner and (3) That said cash, checks, money orders, cash items, paid vouchers, unused accountable forms,
etc., were returned to me intact after the cash count.
Accountable Officer's Signature: Position/Designation: Agency/Station:

SIGNED IN THE PRESENCE OF:

Witness' name and signature: Witness' name and signature
 Annex "E-2

D. STATEMENT OF ACCOUNTABILITY
Name of Funds 1 2 3 4
Revolving Various Trust
Use of Income Misc./Donation
Fund/Meds. Rcceipts
CA# CA# CA# CA#

BALANCE, Last Examination

(Date)

ADD: Debits to
Accountability
(Collections)

See Annex "F" - - - -

Total Debits to Accountability - - - -

LESS: Credits to
Accountability
(Deposits)

See Annex "F" - - - -

Total Credits to Accountability - - - -

Balance of Accountability
0.00 0.00 0.00 -
As of: ____________
Inventory of Cash and/or allowed
0.00 -
Cash Items

Shortage or (Overage) 0.00 0.00 0.00 0.00

CERTIFICATION

I HEREBY CERTIFY that my accountability of the above funds of _________________________ at the time of examination on
__________________ is correctly stated above totalling _____________________________________________________ (₱ )
Accountable Officer’s Signature: Position/Designation: Agency/Station:

I HEREBY CERTIFY that the preceding is a true and correct report of the examination of the Cash and Accounts of:
Name of Accountable Officer: Position/Designation: Date:

Remarks:

Date:
Signature of Auditor/Examiner

INSTRUCTIONS
1. This form will be used for the examination of all cash accountable officers in the corporate, national, and local government offices.
2. Before proceeding to conduct an examination, the examiner should thoroughly familiarize himself with the revised manual on cash
examination.
3. The six (6) columns on the face hereof are left blank to meet all fund requirements.
4. If space provided for is not enough, use it as a summary only and support it with schedules.
5. All reports of examination with their supporting papers and letters will be forwarded to their respective Regional Directors in duplicate. In t
event of shortage/irregularity, the procedures outlined under COA Memorandum 83-81B dated November 1983 should be strictly followed.
6. Checks, treasury warrant, money orders, and other cash items shall be listed on the space for Inventory of Cash Items.
 Annex "E-2"

TOTALS

0.00

0.00

0.00

the time of examination on

__________ (₱ )
 /Station:

Accounts of:
Date:

al government offices.
vised manual on cash

nal Directors in duplicate. In the

should be strictly followed.
sh Items.
Valenzuela Medical Center Annex "F"
WORKING PAPER ON COLLECTIONS AND DEPOSITS
Accountable Officer:
For the period

Summary of Collections:
Trust Fund - Income Trust Fund Revolving Various Trust Receipts Misc./Donation
LBP CA# LBP CA# BTR Acct. No. LBP CA#
DOH IV Total Collections
PHIC-HA/Registratio fluid Refund of HCI-PF
Use of Income Deposit n Fee Total Medicines Access Total C.A. Affiliation Prof. Fee PHIC PF
COPUTER/SYSTEM
Total 1% & 2% Inc. Total
BID DOCS P. Bond/B. Bond PROCESSING FEE
2015 - -
January 2015 -
February 2015 -
March 2015 -
April 2015 -
May 2015 -
June 2015 -
July 2015 -
August 2015 -
September 2015 -
October 2015 -
November 2015 -
December 2015 -
-
January 2016 -
February 2016 -
March 2016 -
April 2016 -
May 2016 -
June 2016 -
July 2016 -
August 2016 -
September 2016 -
October 2016 -
November 2016 -
Dec. 5-31, 2016 -
-
January 2017 -
February 2017 -
March 2017 -
April 2017 -
May 2017 -
June 2017 -
July 2017 -
August 2017 -
September 2017 -
October 2017 -
November 2017 -
December 2017 -
Summary of Collections:
Trust Fund - Income Trust Fund Revolving Various Trust Receipts Misc./Donation
LBP CA# LBP CA# BTR Acct. No. LBP CA#
DOH IV Total Collections
PHIC-HA/Registratio fluid Refund of HCI-PF
Use of Income Deposit n Fee Total Medicines Access Total C.A. Affiliation Prof. Fee PHIC PF
COPUTER/SYSTEM
Total 1% & 2% Inc. Total
BID DOCS P. Bond/B. Bond PROCESSING FEE

- - -

TOTAL - - - - - - - - - - - - - - - - - - -
Summary of Deposits

-
Balance as of - -

Prepared by: Reviewed by:

MA. TERESA S. TAN

Audit Team Member
Summary of Collections:
Trust Fund - Income Trust Fund Revolving Various Trust Receipts Misc./Donation
LBP CA# LBP CA# BTR Acct. No. LBP CA#
DOH IV Total Collections
PHIC-HA/Registratio fluid Refund of HCI-PF
Use of Income Deposit n Fee Total Medicines Access Total C.A. Affiliation Prof. Fee PHIC PF
COPUTER/SYSTEM
Total 1% & 2% Inc. Total
BID DOCS P. Bond/B. Bond PROCESSING FEE

- - -
- - -
- - -
- - -
- - -
- -
- -
- -
- -
- -
- -
Name of Accountable Officer: SONIA S. SADAM
Designation: Administrative Assistant II / Disbursing Officer

RECONCILIATION STATEMENT OF ACCOUNTABILITY

As of

Subsidiary Ledger Balances, P 500,000.00

Add: Items requiring adjustment in the
Subsidiary Ledger:
Unrecorded Replenishment Checks:
TF-UOI P -
TF - Revolving Fund -
Various Trust Receipts
- -
Misc./Donations -
Sub-Total P 500,000.00
Less: Items requiring adjustment in the
Subsidiary Ledger:
Unrecorded Disbursements/Liquidations:

TF-UOI
5/26 - 6/3/2010 P 12,347.75 \
2/1 - 6/9/2010 12,973.50 \
6/10 - 6/24/2010 24,569.50 \ 49,890.75

TF-Revolving Fund
5/7 - 5/20/2010 67,592.33 \
3/17 - 5/27/2010 131,998.49 \
4/20 - 6/19/2010 33,053.40 \
5/19 - 5/26/2010 60,114.77 \
5/7 - 6/23/2010 57,058.96 \ 349,817.95

Various Trust Receipts

4/21 - 6/11/2010 ### 25,398.00 \ 25,398.00

Misc./Donations
12/2/09 - 12/9/09
5/31/10 - 6/18/10 21,721.00 \ 21,721.00 446,827.70

Adjusted Subsidiary Ledger Balance, June 29, 2010 P 53,172.30

Cashbook Balance, June 29, 2010

TF-UOI P 109.25
 TF-Revolving Fund 182.05
Various Trust Receipts 24,602.00
Misc./donations 28,279.00
Adjusted Cashbook Balance, June 29, 2010 P 53,172.30

+ verified from SL balance

\ verified from Report of Disbursements
√ verified from Cashbook/per cash counts
^ footings verified

Prepared by:

MA. TERESA S. TAN

State Auditor II- TM
+

√
√
√
√
√^
 Percentag
Days
Check e of
before
Date No./ ADA Amount Expenses
Replenish
No. Replenish
ment
ed

4/6/2017 139 50,000.00

5/26/2017 212 48,000.00 96% 50
6/28/2017 247 31,710.80 63% 33
8/25/2017 340 33,700.00 67% 58
9/29/2017 461 32,300.00 65% 35
10/18/2017 483 37,627.00 75% 19
12/28/2017 621608 48,200.00 96% 71
2/15/2018 621769 43,371.83 87% 49
4/19/2018 621989 47,110.00 94% 63
8/1/2018 650952 32,337.33 65% 104
10/5/2018 9.92E+09 35,320.00 71% 65
12/10/2018 651366 44,780.00 90% 66
3/26/2019 9.92E+09 23,838.18 48% 106
3/27/2019 651688 35,680.00 71% 1
4/12/2019 9.92E+09 48,620.00 97% 16
5/29/2019 9.92E+09 43,647.50 87% 47
5/31/2019 9.92E+09 19,943.92 40% 2 
171,729.60
34,345.92
Total 656,186.56
 Total the amount of replenishments and divide by the number of replenishments to get the average of disbursements from the PCF, then
38599.21
bursements from the PCF, then let management decide how much to be reduced from the current PCFC so as to resolve the issue raised.
he issue raised.
 STATEMENT OF ACCOUNTABILITY FOR ACCOUNTABLE FORMS WITHOUT MONEY VALUE
As of September 12, 2018

Philippine Orthopedic Center

Name of Accountable Officer: EUGENE M. CHU
Designation : Administrative Aide VI

Balance on Hand Received Since Issued Since Balance of Accountability On Hand Per Actual Count
NAME OF beg.
FORM Inclusive Serial No. Inclusive Serial No. Inclusive Serial No. Inclusive Serial No. Inclusive Serial No. Difference
Quantity From To Quantity From To Quantity From To Quantity From To Quantity From To
Accountable Form No. 51/Official Receipts
TF - UOI
LBP CA#

TF-Revolving
LBP CA#
 Balance on Hand Received Since Issued Since Balance of Accountability On Hand Per Actual Count
NAME OF beg.
FORM Inclusive Serial No. Inclusive Serial No. Inclusive Serial No. Inclusive Serial No. Inclusive Serial No. Difference
Quantity From To Quantity From To Quantity From To Quantity From To Quantity From To

Various Trust Receipts

BTR Acct. #
 Balance on Hand Received Since Issued Since Balance of Accountability On Hand Per Actual Count
NAME OF beg.
FORM Inclusive Serial No. Inclusive Serial No. Inclusive Serial No. Inclusive Serial No. Inclusive Serial No. Difference
Quantity From To Quantity From To Quantity From To Quantity From To Quantity From To

Misc. Donations
LBP CA#

Total

Prepared By:

MA. TERESA S. TAN

Audit Team Member