General Form No.

74 (A) Appendix A
Republic of the Philippines
COMMISSION ON AUDIT

REPORT OF CASH EXAMINATION

Name of Accountable Officer: JULIETA E. LAROT Position: Cashier IV / Revolving Fund Custodian
Agency: Home Development Mutual Fund/Pag-IBIG Fund, Western Mindanao Station: Pagadian Member Services Branch
Maximum Cash Accountability: ₱30,000.00 Amount of Bond:₱22,500.33 Risk No.: 56172460N Effective Date: 07/05/2017
Sonia T. Tan/Nemir Joseph G. Viluan/
Auditor/Examiner: Official Designation: SA III/SA II/SA I/SAE II
Florabel S. Ongcol/Katheryn S. Retorta
A. C A S H PRODUCTION NOTICE
Accountable Officer: Position: Date:
TO
Julieta E. Larot Cashier IV / Revolving Fund Custodian 06/25/2018
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 Revolving Fund Custodian of the Pag-IBIG Fund-Pagadian Member Services Branch 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/Duly Authorized Representative's Signature:
COMPLIED
06/25/2018
WITH
B. C A S H COUNT
INVENTORY OF CASH ON HAND INVENTORY OF CASH ITEMS (Include checks, money orders, etc.)
Paper and Coins: Amount
No. of Particulars
Denomination Amount Presented Allowed Disallowed
Pcs.
Bills
1,000.00 15 ₱ 15,000.00 Schedule I - Schedule of Inventory of 4,655.00 4,655.00
500.00 - - Cash Items
200.00 - -
100.00 2 200.00
50.00 1 50.00
20.00 2 40.00
Coins
10.00 - -
5.00 10 50.00
1.00 5 5.00
0.25 - -
0.10 - -
0.05 - -
0.01 - -
Total as Presented ₱ 15,345.00 Total 4,655.00 4,655.00
TOTAL INVENTORY OF CASH AND/OR ALLOWED CASH ITEMS (TO D) . . . . . . . . 20,000.00
C. INVENTORY OF UNUSED ACCOUNTABLE FORMS
With Money Value Without Money Value
Name of Form Qty. Incl. Serial No. Denomination Amount Name of Form Quantity Incl. Serial No.

Total
CERTIFICATION
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, cash items and unused
accountable forms in my possession and produced to the Auditor/Examiner at the time of cash count today, June 25, 2018 is correctly stated above and
is broken down as follows:

1) Cash and/or cash items . . . . . . . . . . . . . . . . . . . . . . . ₱ 20,000.00

2) Unused accountable forms with money value . . . . . . . none
3) Unused accountable forms without money value . . . . . none

of which (₱ 0.00) 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/Disignation: Agency/Station:

Pag-IBIG Fund-Pagadian Member Services
Cashier IV / Revolving Fund Custodian
Branch
SIGNED IN THE PRESENCE OF:
Witness' name and signature: Witness' name and signature: