Imprest Fund Audit Form for Change in Individual Responsible Instructions
This form should only be completed when making a change to the Individual Responsible of an Imprest
This PDF form is capable of being typed into, so please type out all information except for the bottom signature
It was created to ensure that the new individual responsible physically counts the money prior to assuming the
responsibility of it.
Please fill in the top section of the form in relation to the imprest fund:
o Imprest Fund Number, State Agency, Imprest Fund Name, Street Address, City, State, Zip Code, and
The new individual responsible should be listed under ‘Counted By’ and physically count all of the money
present in the location of the imprest fund, while the current individual responsible observes. This person should
also input the date and time the money was counted. (If the current individual listed responsible no longer is
employed at the agency, another witness may observe.)
If there is any Sales Revenue for the day, list the amount on the ‘Daily Sales/Revenue’ line.
Enter the authorized amount of the imprest fund under ‘Total Dollar Amount of the Fund.’
Subtract the ‘Daily Sales/Revenue’ and ‘Total Dollar Amount of the Fund’ from the ‘Total Dollar Amount
Counted’ and list the difference under ‘Amount Over/Short.
If the amount is anything other than $0.00, please explain the difference in the Commentssection.
The current individual listed responsible should sign and date under ‘Signature and Title of Current Individual
Responsible.’ If this person is no longer employed at the agency, then please note this in the ‘Comments’
The supervisor of the current individual responsible is required to sign as a witness.
If you have any questions after reading these instructions you can contact the State Treasurer’s Office at
(304)558-3599 or email
Once this form has been completed, please fax or email the form to the State Treasurer’s Office, Cash
Management Division at (304)340-1511 or
, along with the Imprest
FundEstablishment/Change Form.
Revised 01/12/15
West Virginia State Treasurer’s Office
John D. Perdue, Treasurer
322 70
Street SE
Charleston, WV 25304
(304) 558-3599
Imprest Fund Audit Form for Change in Individual Responsible
Imprest Fund Number
__________ State Agency _________________________
Imprest Fund Name
State and Zip Code
Counted By _________________________ Date and Time _________________________
Total Dollar Amount Counted ______________
Less: Daily Sales/Revenue ______________
Less: Total Dollar Amount of Fund ______________
Amount Over/Short ______________
Comments _______________________________________________________________________
______________________________________________ _______________
Signature and Title of Current Individual Responsible Date
______________________________________________ _______________
Signature of Supervisor (*Required) Date
Revised 01/12/15