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Clearance Form

DOJ form for clearance

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Revised April 2013

Department of Justice
OFFICE OF THE SECRETARY
Manila
CLEARANCE
This is to certify that

______________________________________, ___________________ in________________________
(full name)

and presently residing at ___________________________________

(position)

with contact details _______________________________________, has been

(residence address)

(contact number/person)

Cleared all accountabilities as of the end office of hours ______________________________, 20_______
(date last day of service)

PURPOSE OF CLEARANCE

Effective on

Cleared of all work assignments and recommending approval _________________________________________

__________

Head of Office

Date

AUTHORIZED SIGNATORY

DATE

1. Outstanding Loan Accounts
OSJEMPC
NPLP
SPPAAI
JUSLA
2. No Pending Administrative Cases
National Prosecution Service
Technical Staff
3. Witness Protection Program, Property & Money Accountability
Program Director/Assistant Director
Special Disbursing Officer
Regional Implementor
4. Inter-Agency Council Against Trafficking (IACAT), Money & Property Accountibility
Budget Division
IACAT Secretariat
5. DOJ Library (Book accountability)
6. Management Information System Division (e-mail address accountability)
7. Financial Service (Outstanding/Unliquidated Cash Advances)
Budget Division

Accounting Division

MOOE
BOC
TEV Local/Foreign
RA 9279 (as collecting officer)
8. Administrative Service
Records Section (records on file)
Supply Section (property accountabilities)
Personnel Division (SALN, ID card & ATM Card)
Leave Section (Service obligation)
Total Leave Credits broken down as
Vacation Leave
Sick Leave
Payroll Section
(Money accountabilites for DOJ Proper/Regional/Provincial/City)

Overpayment
Salary
PERA
RATA
Bonus/Cash Gift
Others
Total Overpayment
Removed from Payroll effective
Final Salary
Final RATA/PERA
Check/fill out the appropriate space provided
 Refunded under O.R. No. ________ dated_____
 To be deducted from terminal leave benefit/retirement gratuity

Other Accountabilities
PLDT
NSFD
Approved
______
Director, Financial Service

Date

NOTE: Issuance of clearance does not relieve the official or employee of accountabilities

______
Director, Administrative Service

Date
 
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