UNIVERSITY OF PITTSBURGH FORM INSTRUCTION GUIDE

FORM TITLE: PETTY CASH REIMBURSEMENT REQUEST
NUMBER:     FORM 0047
PROCEDURE:  05-06-06
DATE:       April 1, 2005


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.