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Attachment IV Request for Replenishment of Petty Cash Fund

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					                                                                                                        Attachment IV

                          Request for Replenishment of Petty Cash Fund
                      (Attach current Reconciliation of Petty Cash, Attachment III)

Petty Cash Fund No. ___________________________                                           Date:     ___________________


Custodian:____________________________________                                          PAC No. ___________________


Amount Requested $__________ FAU: __________ _____ __________ _____ ________
                                                            Account          cc          Fund            Sub       Object

Amount Requested $__________ FAU: __________ _____ __________ _____ ________
                                     Account   cc     Fund     Sub   Object

Amount Requested $__________ FAU: __________ _____ __________ _____ ________
                                     Account   cc     Fund     Sub   Object

Amount Requested $__________ FAU: __________ _____ __________ _____ ________
                                     Account   cc     Fund     Sub   Object

Amount Requested $__________ FAU: __________ _____ __________ _____ ________
                                     Account   cc     Fund     Sub   Object

Amount Requested $__________ FAU: __________ _____ __________ _____ ________
                                     Account   cc     Fund     Sub   Object

Amount Requested $__________ FAU: __________ _____ __________ _____ ________
                                     Account   cc     Fund     Sub   Object


Write object code on each receipt.                         TOTAL requested : _____________________________
Petty cash disbursements (supported by attached itemized list and receipts) should be charged to the accounts/funds shown above.

This certifies that I have reviewed and verified this report. All expenditures reported herein are in
compliance with University policies.


_________________________________                              __________________________________________
Signature of Custodian                                             Signature of Department Head

_________________________________
Accounting Services Approval
                                                              Reconcile your Petty Cash Fund at least on a monthly basis and
                                                                          requesting replenishment of Petty Cash Fund.
Request for Replenishment of PC Fund                                                                             Revised: 10-22-10

				
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