PETTY CASH CUSTODIAN
REPLENISHMENT REQUEST
Name Date Submitted
Department Telephone No.
1. - - cash count 2. - - total receipts being submitted
Bills
100.00
50.00
20.00
10.00
5.00
Coins
2.00
1.00
_ 0.25
0.10
0.05
0.01
TOTAL CASH ON HAND
TOTAL CASH ON HAND PLUS TOTAL RECEIPTS
LESS: ORIGINAL FLOAT AMOUNT
DIFFERENCE = CASH SHORTAGE (OVERAGE) *
* If shortage (overage) is more than $ 2.00, please provide details
Complete Account No. Total Amount
TOTAL RECEIPTS
SIGNATURE OF PETTY CASH CUSTODIAN
DEPARTMENT COUNTERSIGNATURE
FINANCIAL SERVICES USE ONLY
VENDOR # VOUCHER #
VERIFIED APPROVAL
Revised April 30, 2012
0.00
100
0.00
50
20
0.00
0.00
10
0.00
5
0.00
2
1
0.00
0.25
0.10
0.00
0.00
0.05
0.00
0.01
$0.00
0.00
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