Request for Petty Cash Fund

REQUEST FOR PETTY CASH FUND

CALIFORNIA STATE UNIVERSITY, LONG BEACH FOUNDATION
(562) 985-5430
Vendor #
ARE YOU A FIRST TIME PAYEE? IF SO, COMPLETE SUBSTITUTE W-9 FORM AND RETURN IT TO ACCOUNTS PAYABLE BEFORE PAYMENT WILL BE MADE. ON FILE ATTACHED
Before a Petty Cash Fund is established, this form must be completed by the project making the request. The purpose, location, and means for safekeeping the fund must comply with relevant Foundation policies and procedures. If the request is accepted, a check for the approved amount will be debited to the project (s) petty cash G/L (100200), encumbered to the project (s) petty cash G/L (515500) and made payable to the Petty Cash Custodian named below. Once established, the fund can be replenished using a Petty Cash Settlement/Reimbursement Request. If you are requesting a change in petty cash amount, be sure to check the appropriate boxes and complete amount sections.
Dept. Ref. #
Custodian Name
Check to be distributed as follows
Project or Grant Name / U. S. Mail
100200 / Payee/Dept. Staff Pick-up
Project or Grant Number (8 digits) / Name
Payee’s Ext
Total Dollar Amount Requested / Payee must present appropriate I.D. before check will be released.
Change in Amount Requested by $ / Increase Decrease
REQUIRED:
Project Justification/Purpose of Expenditure:
Physical Location of Fund:
Building: / Room Number:
Means of safekeeping against theft and tampering:
Safe Locked Cash Box Locked Desk or File Locked Room (limited Access)
I certify that this Petty Cash Fund will be administered in accordance with the policy requirements of ABS 83-13, with the educational mission of the University, the policies and procedures of the Foundation and with restrictions imposed by the funding source or donor. By signing this document I certify I have read and will comply with the above requirements.
Name of Custodian (Type or Print) / Title of Custodian / Custodian’s SSN (last 4 digits)
** (If new payee, submit Sub W-9 form to AP before payment will be made)**
Signature of Custodian / Date / Phone Number
Project Director’s Signature / Date / Phone Number
Foundation Use Only / Encumbrance
Project # / GL# / Amount / PO#
A/P Tech Approval/Date / Allowability Approval/Date

INSTRUCTIONS

REQUEST FOR PETTY CASH FUND

CALIFORNIASTATEUNIVERSITY, LONG BEACH FOUNDATION

(562) 985-8603

CUSTODIAN NAME - Print the name of the custodian of the petty cash fund

PROJECT OR GRANT NAME AND NUMBER – This is the project title and number (8 digits)

TOTAL AMOUNT REQUESTED – The amount of cash needed for the project as authorized by the Project Director.

CHANGE IN AMOUNT (INCREASE/DECREASE) – This form may also be used to request change in the amount of petty cash fund.

DEPT. REF. # - This reference number is supplied by the project to simplify reconciliation of monthly reports. The Foundation will enter this number when paying the request. Use of this reference number is optional. The number will appear on the transaction’s reference line on the monthly report.

PROJECT JUSTIFICATION/PURPOSE OF EXPENDITURE – State the reason for establishing the petty cash fund and what you are using the funds to buy.

PHYSICAL LOCATION OF FUND – Indicate the building and room number where the petty cash fund will be physically located.

MEANS OF SAFEKEEPING – Check the appropriate box and identify the level of security. The level of security depends on the amount of cash and how the cash will be disbursed. Generally, departments should not keep large amounts of cash in a petty cash fund. In all cases, petty cash and records should be held in a locked cash box or safe and located in a secure (lockable) room with limited access. Cash boxes also should be locked in a desk or cabinet out of the general view of other employees and the public. Only one individual, the Custodian, shall have access to the petty cash fund.

NAME AND TITLE OF CUSTODIAN – Print the name and title of the Custodian who is the person receiving the petty cash fund.

CUSTODIAN’S SOCIAL SECURITY NUMBER – Only last 4 digits are necessary for verification. If a first time payee, complete and submit a Substitute W-9 form before payment will be made. The form may be downloaded from our website, (www.foundation.csulb.edu), click on forms. Payment will not be processed without the Social Security number of the Custodian.

SIGNATURE OF CUSTODIAN – Signature of petty cash custodian, who is the person receiving the petty cash funds.

DATE AND PHONE NUMBER- Date Custodian requested petty cash fund and on campus phone extension or off-campus phone number where Custodian normally engages in business.

PROJECT DIRECTOR/AUTHORIZED SIGNER SIGNATURE – The Project Director or Authorized Singer must approve by signing

DATE AND PHONE NUMBER – Date authorization obtained and on-campus phone extension or off-campus phone number where the Project Director or Authorized signer normally engages in business.

ENCUMBRANCE BOX – For Foundation Use Only

AP004 All Foundation forms can be downloaded from our website: October 2011