UNIVERSITY OF PITTSBURGH FORM INSTRUCTION GUIDE 

FORM NUMBER:      FORM 0047

FORM TITLE:            Petty Cash Reimbursement Request

PROCEDURE:           05-06-06

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

      Fund amount.

2.   Funds on Hand Enter the cash remaining in Fund, i.e. cash on hand and available

      bank funds.

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

      custodian.

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

      only.

19. Page Enter page number(s). If multiple pages, list sequence, e.g. 1 of 3.