Attachment to MEMORANDUM NO. 2003-10
PETTY CASH FUND REPORT
| As of ___________ | |||
| Agency: | (1) Name________________________________________ | Number_____ | |
| Contact Person: | ______________________________________________ | ||
| Please print name and phone number | |||
| Fund: | |||
| 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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