Petty Cash Form

Account to Charge:

Index:

Acct:

or
Fund:

Org:

Acct:

Prog:


Name:




Amount:

Reason or Description: _________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

Department:


Contact for Inquiries:




Ext:




________________________________________________
Approving Signature* Date
*(Must be different than individual receiving reimbursement and picking up cash)



***Please note:

-Original receipts required
-All receipts must be itemized
-$50 Maximum
-Maximum applies per person, per day



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**For office use only**

Cash Received by: _________________________ Date: ___________