Department of Finance & Management
Financial Operations Division
th Floor 109 State St – 4
Montpelier, VT 05609-5901
PETTY CASH VERIFICATION FORM
Per VISION Petty Cash Procedure # 5 (revised 06/21/2007), please complete this form regarding the
Petty Cash (Imprest) Fund indicated below (as of June 30) and forward to Financial Operations by July 30.
PETTY CASH ACCOUNT INFORMATION
Petty Cash Fund Description/Name:
Fund authorized amount: $ Program #:
Department or Agency:
Custodian contact information - Phone: 802/ - e-Mail:
PROOF OF ACCOUNT BALANCE (to be completed by custodian)
Cash on Hand (Change fund in a cash box, safe, etc.) $
Un-replenished disbursements: $
Replenishment check(s) to be deposited or cashed $
Bank account balance (if applicable): $
Bank account number:
Bank account name:
Bank name, address:
(A. + B. + C. + D.)
(Must equal E. below.)
I have verified the petty cash fund description and amount listed above and find that the account total, including un-replenished documented disbursements and not deposited replenishment(s) at the close of business on June 30, (enter FY) is:
* Important: Appointing Authority refers to agency secretaries, department commissioners, elected officials, and their deputies, or, heads of divisions, boards, and commissions not reporting to a department commissioner.
Printed Name & Title of Appointing Authority
Please select one of the following certification options:
(a.) Electronic Certification Option for Appointing Authority
By checking this box (with a left mouse click), I authorize the Department of Finance and Management to accept this document transmitted from my State email account as our official submission. In addition, I certify that my name as typed above shall be treated as my written signature from the purpose of certifying this document.
**Important: To electronically certify, an X must be placed in the space indicated and the verification form must be sent
by the Appointing Authority from his/her State email account to Finance and Management at the email address below.
(b.) Signed Certification Option for Appointing Authority
If electronic certification is not used, then this Verification form must be signed by the Appointing Authority and mailed to Finance and Management at the address below.
Appointing Authority Signature & Date
Please return this completed form no later then July 30 to:
Melanie Rutledge – Financial Operations
Department of Finance and Management th109 State Street – 4 floor
Montpelier, VT 05609-5901
The Petty Cash Procedure can be found on the VISION website at: