Name of Department:

Petty Cash Account Number:

1. Total Amount of Petty Cash Fund:
   

2. Cash on Hand:
   

3. Receipts for Expenses:
   

4. Total of #2 and #3
   

5. Account Balance- #1 minus #4 (should equal zero):
   

6. Account Balance is     Greater than beginning cash balance
                                      Less than beginning cash balance

    Date Submitted:
   

    Responsible Person: