PETTY
Y CASH REECONCILIA
ATION FOR
RM Date Departmentt Petty Cash FFund Number Chartfield Check All T hat Apply:  Repoort to Approvver 
Chan
nge of Custod
dian: From: To: 

Chan
nge of Appro
over: From: To: Pettty Cash Fund Close Out Cash on Hand Receipts on Hand Total Cash and Receipts Petty Cash Fund Original Amount Difference Amoun
nt $ $ $ $ $ ny) and remedial plan to aaddress differrence: Reeason for difference (if an
I have verified
d fund status and agree to
o this reconciliation reporrt: _____________
____________
___________
________
___________________________________________ Cu
ustodian Sign
nature CCustodian Nam
me _____________
____________
___________
________
___________________________________________ Approver Signaature A
Approver Nam
me I h
have verified
d fund status, agree to thiss reconciliatio
on report, an
nd assume maanagement o
of the fund: _____________
____________
___________
_________
___________________________________________ Newly Appointted Custodian
n or Approverr Signature
N
Newly Appoin
nted Custodian or Approveer Name Re
ev. 11 October 20
010