UNIVERSITY OF PITTSBURGH FORM INSTRUCTION GUIDE
FORM NUMBER: FORM 0047
FORM TITLE: Petty Cash Reimbursement Request
EFFECTIVE DATE: April 1, 2005
PAGE (S): 1
PLEASE PRINT LEGIBLY OR TYPE.
Refer to University Policy 05-06-06 for detailed instructions.
Do not complete shaded areas of form.
1. Amount of Fund – Enter the Petty Cash Fund imprest balance, i.e., the Petty Cash
2. Funds on Hand – Enter the cash remaining in Fund, i.e. cash on hand and available
3. Amount of This Request – Enter the amount requested for reimbursement.
4. Request No. – Assign a unique number for each request.
5. Name of Petty Cash Custodian – Enter the complete name of Petty Cash Fund
6. SITE ID – Enter the unique number assigned by General Accounting.
7. Phone Number – Enter the phone number of the Petty Cash Custodian.
8. School or Department Affiliation – Enter the School or department affiliation.
9. E-Mail Address – Enter the e-mail address of the custodian.
10. Street Address – Enter the street address of the custodian.
11. City, State, and Zip Code or Foreign Country – Enter the city, state, and zip code or
foreign country of the custodian.
12. Account Number – Account number(s) to be charged.
13. Date (Month/Day/Year) – Enter the transaction date (mm/dd/yy).
14. Description – Enter a brief description of the items. (Include bank fees and interest
earned on the request.)
15. Amount – Enter the amount charged (or credited in the instance of interest earned).
16. Signature – Obtain the signature of the Petty Cash Custodian.
17. Request Date – Enter the current date (mm/dd/yy).
18. Total – Total amount of request. Include total of a multiple-page request on the last page
19. Page – Enter page number(s). If multiple pages, list sequence, e.g. 1 of 3.