As of ___________

Department: (1) Name_____________________________ Department Acronym______

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) Departments 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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