STATEMENT OF CHARGES/CASH COLLECTION VOUCHER
2. DOCUMENT/VOUCHER NUMBER
5. DISBURSING OFFICE COLLECTION
6. DISBURSING STATION SYMBOL NUMBER
7. ACCOUNTING CLASSIFICATION
8. TYPE OR ACTION (Select one)
a. PAYROLL DEDUCTION
b. CASH COLLECTION
c. GRAND TOTAL
9. CERTIFICATION OF RESPONSIBLE INDIVIDUAL
I certify that my signature hereon constitutes
a. An authorization to recover the amount of the indebtedness through payroll deduction, if payroll deduction is checked. If cash collection
is checked, I am remitting debt in cash.
b. An affirmation that the articles are not now in my possession.
c. An agreement to turn-in to the appropriate supply officer all articles later recovered, it being understood that the U.S. Government
retains title to the articles listed hereon.
e. NAME (LAST, First, Middle Initial)
g. CAUSE FOR
f. SOCIAL SECURITY NUMBER
10. ORGANIZATION COMMANDER
11. DISBURSING OFFICER OR PAYROLL CERTIFYING OFFICER
The amount entered in grand total has been (FAO) check the appropriate
The statements hereon are complete and correct. All
damaged property has been disposed of in accordance
a. Entered on the appropriate pay record or payroll, or DD Form 139
with current directives and the charges have been
has been prepared and forwarded for collection.
computed in accordance with the provisions of AR
735-5, Appendix B.
b. Remitted through cash collection.
b. SIGNATURE BLOCK/SIGNATURE
d. SIGNATURE BLOCK/SIGNATURE
DD FORM 362, JUL 93
Previous edition may be used.