MEMORANDUM NO. 99-15 Attachment

EXHIBIT 12-4

PETTY CASH FUND REPORT

As of ______________
Agency: (1)Name ________________________________ Number________
Contact Person: _______________________________________
Please print name and phone number
Petty Cash Advances
Fund: General Fund Other Funds(3)
Authorized Balance:
Actual Cash on Hand __________ __________
Actual Cash in Bank __________ __________
Receipts for Expenditures on Hand __________ __________
Travel and Other Advances Outstanding __________ __________
Total __________ (2)__________
I have examined this report and any attachments and certify that it is correct. I have examined the use of this petty cash fund during this past year and certify that its use has been as prescribed by the State Accounting Manual, Imprest Petty Cash Funds, except as indicated on an attachment.
Further (check one)
______ The full authorized general fund balance is still needed.
______ $___________ is in excess of our needs and will be returned.
_______________________ _________________________
Signature Title
  1. Agencies with a "consolidated" petty cash fund need send only one consolidated report, however, the portion of the fund of each sub-unit should be shown on an attached sheet.
  2. Explain any discrepancy between this total and the Authorized Balance.
  3. Please identify the sources of advances from other funds.

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