Application to Establish
or Dissolve a Fund
Agency________________________________________________________ Date ________________________
Address _____________________________________________________________________________________
Official Name of Fund___________________________________________________________________________
Fund Creation Fund Dissolution Petty Cash/Change Fund Increase/Decrease
Type of Fund
Legislatively Created State Trust Fund Federal Trust Fund Locally Held Trust Fund
Temporary Locally Held Trust Fund or Bank Deposit Petty Cash Fund Change Fund
Statute: _________________________________________
Questions Applicable to All Funds
1. Purpose of Fund: __________________________________________________________________________
2. Sources of Receipts: _______________________________________________________________________
3. Purposes of Disbursements: _________________________________________________________________
4. Length of Time Fund Required: _______________________________________________________________
5. Requested Effective Date: ___________________________________________________________________
Questions Applicable to Locally Held, Petty Cash and Change Funds
6. Who is Accountable for Fund:_________________________________________________________________
7. Are Persons Handling Moneys Bonded: ______________ Explain: _________________________________
8. Location of Fund: __________________________________________________________________________
9. If Petty Cash Fund: Amount of Petty Cash Requested: ____________________________________________
Social Security Number of Custodian: __________________________________________
Questions Applicable to All Fund Dissolution
10. Current Fund Balance: ______________________________________________________________________
11. Disposition of Remaining Balance:_____________________________________________________________
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Signature of Agency Head Date Telephone Number
Approval Granted Approval Denied
Fund Number
Fund Name: _________________________________________
_________________________________________ ____________________
C-68 Side 11/2020
Survey Of The Need For A Petty Cash Fund
Part A: Internal Control Over Petty Cash Fund. (Please attach internal operating procedures to this application.)
Instructions: Please check the appropriate column for each of the following questions.
1. Will one person be responsible for the Petty Cash fund?
2. Will daily cash receipts be commingled with the Petty Cash Fund?
3. Will the petty cash be maintained in whole or in part in a bank account?
3a. Will the bank be notified in writing not to accept checks payable to
the agency?
3b. Will cash be deposited in the bank account?
4. Will checks for reimbursement of petty cash be made from the Fund?
5. Will single payments of $50.00 or more be made from the Fund?
6. Will approval by someone other than the custodian be required for
7. Will supporting data for disbursement from petty cash be required and
adequately examined for reimbursement?
8. When petty cash is reimbursed will notation of payments be made on
the supporting document to prevent duplicate payment?
9. Will employee paychecks and personal checks be cashed out of petty
cash? Will advances be made to employees?
10. Will a reconciliation of the petty cash be made on a regular basis by
someone independent of the custodian?
11. Will the petty cash be audited by internal auditors or other independent
Part B: Dollar Level Determination of Fund
Total Number of Transactions during year less than $50 ______________ .
Total Dollar Amount of Transactions during the year less than $50 ______________ .
Total Dollar Amount of Transactions divided by six = ______________ Amount of Fund Needed.
C-68 Side 21/2020
Yes No