Petty Cash Reimbursement Voucher
RETURN FORM TO:
Office of Student Accounts, 300 College Park, St. Mary’s Room 108, Dayton, OH 45469-1601
Department Name: Department Contact:
Department Zip: Contact Phone:
Department FOAPAL String:
FUND ORGANIZATION ACCOUNT PROGRAM ACTIVITY LOCATION AMOUNT
Amount Disbursed: Date of Disbursement:
Disbursement Signature Approvals
Requestor Signature
Print Requestor Name
Date
Department Head/Budget Manager Signature
Print Department Head/Budget Manager Name
Date
Vendor Name & Address:
Item(s) Purchased: (Please attach the purchase receipt to
this form. If no receipt was obtained, please explain why.)
University Business Purpose:
Balance Returned: Date of Return:
Return Balance Signature Approval
Department Head/Budget Manager Signature
Print Department Head/Budget Manager Name
Date