REPORT OF DISBURSEMENTS

Agency Period Covered:

DateDV/Payroll Responsibility

PayeeNo. Center Code

CERTIFICATION I hereby certify that this Report of Disbursements in _____ sheets is a full, true and correct statement of the disbursements made by me and that this is in liquidation

per Check No. _____________ dated ______________.

Disbursing Officer

of the cash advance granted last ___________ in the amount of P_______________

Report No.:_________Sheet No.: _________

Appendix 56

Date

Nature of Payment Amount

125A

O 6/15/02