WHO SHOULD USE The Departmental Cash Fund Replenish Form:
The use of this form is limited to departments that maintain their own petty cash fund.
WHEN TO USE THIS FORM:
Submit this form to the Working Fund Office at least once a month to replenish the
Departmental petty cash fund. Only cash purchases can be reimbursed using this form.
HOW TO COMPLETE THIS FORM:
Expense Itemization Each expense must be supported by an original receipt.
Vendor: List the name of the company from which the goods or services
were purchased.
Amount: Cost to be reimbursed. If the cash register receipt contains items
not to be charged to petty cash (personal expenses), cross these
amounts off the receipt.
Dept or Grant: The department or grant to which the expenditure should be
charged and the 6 digit account (subcode) number.
Total of Voucher: Total of the amount column. Each amount must be supported by a
receipt.
Cash Drawer Audit Reconciliation of the departmental petty cash fund.
Cash in Drawer: Cash on hand.
Total Receipts: Petty cash used. These expenditures must be supported by receipts
and match the amount total in the Expense Itemization section.
Petty Cash Fund: Original amount of cash in the petty cash fund. Cash in drawer plus
Total Receipts = Petty Cash Fund.
Reason for Payment: Short explanation as to the reason each item was purchased.
Make Check Payable To: Checks must be made payable to the department’s petty cash
custodian.
Signature of Requestor: The signature of the department’s petty cash custodian.
Dept/Div Head Signature: The signature of an employee who is authorized to sign for the
charge code to which the expense is being charged.
