OHIO TREASURER OF STATE
CUSTODIAL ACCOUNT BANK ADJUSTMENT FORM
Agency Name:
Custodial Account Name:
Bank Name:
Last four digits of bank Account No:
Adjustment Settlement Date
as Reported by Bank
Total Amount for the Day
Authorized Signature:
Title:
Agency Contact Name & Phone Number:
Date Completed by Agency:
This form should be completed for the total amount of ADJUSTMENTS reported by the bank for each settlement date.
E-mail to: General_Ledger@tos.ohio.gov
Credit Adjustment
Debit Adjustment
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