REQUEST TO REPLENISH PETTY CASH FUND
CO-17RPC REV. 7/03 (Stock No. 107-01)

STATE OF CONNECTICUT
OFFICE OF THE STATE COMPTROLLER

STATEMENT OF PETTY CASH FUND (AS OF REQUEST DATE)

(1) ON HAND

(2) IN BANK

(3) IN BRANCHES

(4) ADVANCES

(5) LISTED EXPENDITURES

(6) OUTSTANDING EXPENDITURES

(7)

AUTHORIZED PETTY CASH

ATTACH SUPPORTING DOCUMENTS FOR ALL INDIVIDUAL EXPENDITURES

 
.

(I0) DOCUMENT AMOUNT

$

(13) DOCUMENT DATE

PETTY CASH CUSTODIAN

DESCRIPTION

(20)
AMOUNT

(34) DATE SIGNED

(33) AUTHORIZED SIGNATURE OF PETTY CASH CUSTODIAN

I CERTIFY THAT THE EXPENDITURES LISTED ABOVE REPRESENT STATEMENT OF PETTY CASH AND PROPERLY AUTHORIZED DISBURSEMENTS FROM THE PETTY CASH FUND ALLOTTED TO THIS DEPARTMENT

GL UNIT

BUDGET
DATE

(32)
BUDGET
REFERENCE

(30)
CHARTFIELD
1

CHARTFIELD

 
SID

(27)
PROGRAM

(28)
ACCOUNT

(29)
PROJECT/
GRANT

(30) SID

(31)
CHARTFIELD
2

((21) QUANTITY

(18)

AMOUNT

(24)

FUND

(25)

DEPARTMENT

(19)

TOTAL

(14) PAYEE

(17)

(9) DOCUMENT NUMBER

(26)

(16)

DATE

(22)

(23)

(8)

BUSINESS UNIT NAME

(15) PREPARED BY

VOUCHER NUMBER

(11)

VOUCHER DATE

(12)

STATE