Department of Finance & Management

    Financial Operations Division

    th Floor 109 State St – 4

    Montpelier, VT 05609-5901

    802/828-2434 (Fax)

     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 #:

Advanced to:

    Department or Agency:

    Division/Program Name:

    Address, City:

    Fund Custodian:

    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.) $

     A.

Un-replenished disbursements: $

     B.

Replenishment check(s) to be deposited or cashed $

     C.

Bank account balance (if applicable): $

     D.

    Bank account number:

    Bank account name:

    Bank name, address:

     $

     (A. + B. + C. + D.)

     (Must equal E. below.)

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VERIFICATION

    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:

    $

     E.

    * 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

    E-mail: melanie.rutledge@state.vt.us

    The Petty Cash Procedure can be found on the VISION website at:

    http://finance.vermont.gov/sites/finance/files/pdf/vision_procedures/VP_5_Petty_Cash.pdf

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