CONFIRMATION OF PETTY CASH FUNDS PLACEMENT IN BURSAR’S OFFICE VAULT
Originating unit retains original bearing signatures, including of Bursar’s Office representative; a photocopy remains in the
Bursar’s Office.
From (Department or Unit):
Name
Telephone
Address
Petty cash fund #
Z
Custodian (Print name)
Approver (Print name)
Approver Signature
Place in vault:
Total Cash/Coin
$
Total Gift/Debit cards #
In front of Bursar’s Office representative confirm items being given to be put in vault, by signing and dating below.
Person delivering funds (Print name)
Signature
Date
Bursar’s Office Receipt:
In front of person delivering funds, confirm items received, note banker’s bag # and placement in vault, below.
Bursar’s Office Representative (Print name)
Signature
Date
Number of banker’s bag placed in vault #
Withdrawal from Vault (Upon completion of section, originating unit retains original; copy remains in Bursar’s Office.)
Total Cash/Coin
$
Total Gift/Debit cards #
Signature of person withdrawing funds
Date
Signature of Bursar’s Office Representative
Date
6 2 7 B r o a d wa y , 7 th Fl o or | Ne w Y o r k, NY 1 0 0 12
2 1 2 9 9 8 5 0 7 0 | 21 2 9 95 4 7 7 8 f ax | ste in h a rd t.ny u .e du /a d mi nfi n a nce