Petty Cash Reconciliation Template

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					                                                             Northwest Regional ESD                                              Form 57
                                                             Petty Cash Reconciliation
                                                                                                                    Submit this form on a
                                                                                                                       Monthly Basis.

             Issued to:                                                                                              Final Petty Cash
                                                        (Petty Cash Custodian's Name)                            Reconciliation for the fiscal
     Program name:                                                                                                      year is Due
                                                                                                                         May 15th.
                                     *Original Amount of Petty Cash: $                                      -

     Date of                            Cash issued to                         Description of Transaction        Amount of            Cash on
   Transaction                         or received from:                                                        Transaction            Hand
                                                                                                                               (automatically subtracts)
                                                                                                                          -                        -
                                                                                                                          -                        -
                                                                                                                          -                        -
                                                                                                                          -                        -
                                                                                                                          -                        -
                                                                                                                          -                        -
                                                                                                                          -                        -
                                                                                                                          -                        -
                                                                                                                          -                        -
                                                                                                                          -                        -
                                                                                                                          -                        -
                                                                                                                          -                        -
                                                                                                                          -                        -

Instructions:
1. Use this log for all petty cash transactions.
2. For reimbursement of funds:                                              Petty Cash Custodian Signature:
   a.) Photo copy completed log(s).
   b.) Summarize account numbers and amounts of
               reimbursements on a Request for Check.                            Coordinator Signature:
   c.) Attach all original receipts.
   d.) Obtain proper authorizations and submit to Fiscal
          Services by Friday for a check the following Friday.

*All receipts plus cash on hand should add up to the original amount of the petty cash fund.
Fiscal Services   Revised 7/1/2007

				
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