Revised 12-04-15
Imprest Fund Establishment/Change Form
1. Please designate the type of request:
_____ Establish a New Imprest Fund _____ Change the Individual Responsible or the Supervisor (*see #8)
_____ Change the Address or Location _____ Increase or Decrease the Amount of the Imprest Fund
_____ Seasonally Close Imprest Fund _____ Permanently Close Imprest Fund
2. *Enter the imprest fund number: _______________________________ *If new request, this will be assigned
when approved by the Treasurer's Office.
3. Enter the name of the imprest fund: _________________________________________________________________
4. Enter the purpose of the imprest fund: _______________________________________________________________
5. Enter the location of the imprest fund: _______________________________________________________________
6. Enter the address where correspondence should be sent on the imprest fund:
Address 1: ________________________________________________________________________________
Address 2: ________________________________________________________________________________
City: _____________________________ County: ____________________ State: ________ Zip Code: _________
7. Enter the following information for the individual responsible for this imprest fund:
Name: ____________________________________________ Email: ________________________________________
Title: _______________________________________________________
Phone Number: ______________________________________________
Supervisor: __________________________________________________
8. If this request is to Change the Individual Responsible the Audit Form for Change in Individual Responsible MUST be
attached (NOTE: the audit form does not need to be complete when changing Supervisor).
9. Enter the authorized amount (Before Request): $____________________ (After Request): $_________________
10. If this is a request for a change in the authorized amount, please provide an explanation for the change.
11. wvOASIS Funding Information: Fund:_____ Sub fund:______ Dept:_____ Unit:______ Obj:3296_ Sub Obj:_____ Proj._____
12. Please affix signature to the appropriate section
Requesting Central Office Office of the
Agency of the Agency State Treasurer
Signature: ___________________________ ______________________________ _____________________________
Date: ___________________________ ______________________________ _____________________________
Accounting Division
322 70
Street SE
Charleston, WV 25304
Phone: (304) 558-3599
Fax: (304) 340-1511
Revised 01/12/15
Imprest Fund Establishment/Change Form Instructions
This PDF form is capable of being typed into, so please type out all information except for the bottom
signature lines.
If you have any questions after reading these instructions you can contact the State Treasurer’s Office
at (304)558-3599 or email
1. Please designate the type of request.
Check the box(s) that apply.
2. Enter the Imprest Fund Number.
This will be a five-digit number authorized by the STO. If you are unsure of the imprest fund
number, please contact the STO. (Note: If this is a request for a new imprest fund, this
number should be left blank. The STO will fill this in later.)
3. Enter the name of the Imprest Fund.
This is chosen by the agency and should be related to what the imprest fund is for. For
example: “Business Office Change Fund” or “Gift Shop Change Fund,” etc.
4. Enter the purpose of the Imprest Fund.
Please explain what the imprest fund money will be used for. For example: “to make
5. Enter the location of the Imprest Fund.
This should be the exact location of where the imprest fund is kept. If the address is different
than the address in #6, then please list the full address here. Otherwise, if it is the same
address then a brief description will be sufficient. For example, “Business Office – Building
5” or “Bursar’s Office,” etc.
6. Enter the address where correspondence should be sent on the Imprest Fund.
This address should be the mailing address where any imprest fund-related correspondence
should be sent to.
7. Enter the following information for the individual responsible for this Imprest Fund.
The Individual Responsible is the person who is held accountable for the imprest fund. Please
type in this person’s name, email address, title, and phone number. The supervisor should be
the person who is over the Individual Responsible.
8. If this is a change in individual responsible for the imprest fund, please provide the following
Revised 01/12/15
When a new person assumes responsibility for an imprest fund, the new person should
immediately count the funds prior to assuming responsibility. Please input the date and
amount that was verified.
9. Enter the authorized amount (Before Request) and (After Request).
This depends on:
i. If this is a new imprest fund the before amount will equal $0.00 and the after amount
will equal whatever the desired imprest fund amount is.
ii. If this is an increase/decrease to an imprest fund, the before amount would be the
authorized amount before the increase/decrease and the after amount would be the
new desired imprest fund amount.
iii. If this is any other change, the before and after amount should be the current
authorized amount of the imprest fund.
10. If this is a request for a change in the authorized amount, please provide an explanation for the
Please list why this imprest fund needs to be increased or decreased.
11. wvOASIS Funding Information.
When an Imprest Fund is established or increased a wvOASIS GAX document is entered by
the agency’s accounting department to supply the imprest fund. When an imprest fund is
closed or decreased a wvOASIS CR document is entered to put the money back into the fund
of which it came out of. The funding for the wvOASIS CR/GAX should be entered here. If
the individual filling out the change form does not know this information, the individual
should check with their agency’s accounting department or business office. (Note: The
Object code should always be 3296 for Imprest Funds.)
12. Please affix a signature to the appropriate section.
The Individual Responsible or Supervisor must sign this form under ‘Requesting Agency’ in
order for the change form to be processed. If the agency requires additional signatures for
internal controls, then these may be placed under ‘Central Office of the Agency.’
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
*Note If this is a Change in the Individual Responsible of the Imprest Fund, the State
Treasurer’s Office also requires that the Imprest Fund Audit Form be filled out and submitted
along with the Establishment/Change Form.
The STO will then sign off on the form and email/fax the approved copy back to the agency for
their records. If the change requires a wvOASIS CR or GAX, the agency will make a copy of
the approved form to attach as backup with the CR/GAX Coversheet that will then go to the
Auditor’s Office.