State of Connecticut



As of ___________
Agency:  (1)Name________________________________________ Number_____
Contact Person:______________________________________________
Please print name and phone number
Petty Cash Advances
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 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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