Unitatea .........................

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| DISPOZIIE DE*) ......................................... CTRE CASIERIE |
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nr. ............... din ..................
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| Numele i prenumele ...................................................... |
| Funcia (calitatea) ...................................................... |
| Suma .................... lei ............................................ |
|
(n cifre)
(n litere)
| Scopul ncasrii - plii ................................................ |
| .......................................................................... |
|____________________________________________________________________________|
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Viza de control
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Compartiment
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|Conductorul unitii| financiar-preventiv | financiar-contabil |
| Semntura |_____________________|_____________________|____________________|
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|___________|_____________________|_____________________|____________________|
*) Se va nscrie "NCASARE" sau "PLAT", dup caz

(verso)
____________________________________________________________________________
|
|
DATE SUPLIMENTARE PRIVIND BENEFICIARUL SUMEI:
|
| Se completeaz |
|
| numai pentru
| Actul de identitate .............. Seria ..... nr. ...... |
| pli
| Am primit suma de .............................. lei
|
|
|
(n cifre)
|
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Data .........................
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Semntura ....................
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|________________|___________________________________________________________|
|
CASIER
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| Pltit/ncasat suma de ............................... lei
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|
(n cifre)
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Data .........................
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Semntura ....................
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|____________________________________________________________________________|