CUSTODIAL ADJUSTMENT REQUEST
TO: Treasurer, State of Ohio DATE:
Attn: Accounting Department
FROM:
(Agency name and Account name)
(Bank name and Account number)
Please adjust the following:
Deposit
Date of Deposit
Document#
Withdrawal
Date of Withdrawal
Document#
Original amount reported to the Treasurer $
Correct Amount $
Authorized Signature
Instructions: This document is used to report adjustments to a previously reported deposit
or withdrawal.
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