University of Pennsylvania
Petty Cash Custodian Responsibility Form
(rev. 5/07)

PART I
**Custodian Name:    Penn ID:
Custodian Telephone Number: - -    E-Mail:
Responsibility Center Code:      Department Name:
Campus Address:

Petty Cash Fund Number (26 digits): - - - - - -

CNAC

ORG

FUND

OBJC

PROG

CREF

**NOTE: If changing Custodian, Part I should contain new custodian information.

PART II
	Current Fund Amount	Amount: $
	Establishment of Petty Cash Fund (Please provide a letter of purpose)	Amount: $
	$ increase of petty cash	New Amount: $
	$ decrease of petty cash	New Amount: $

Change custodian from: to:

Close Petty Cash fund: If, for any reason, a fund is no longer required, a fund must be closed by completing and submitting an on-line deposit via BEN Deposits using Object Code 1140. Deliver the summary deposit along with the cash to the Office of the Cashier, Rm 110 Franklin Buidling. Then send a completed Petty Cash Custodian Responsibility Form, along with the original hand-stamped deposit sheet to the Office of the Cashier, Room 110 Franklin Building, 3451 Walnut St. Attn: Tammy DeSalis

This fund and responsibility is issued to the above named custodian. I, , accept the above stated petty cash fund with the understanding that I have read Financial Policy 1506 and am personally responsible for the proper safekeeping and use of said funds. It is further understood that I will be personally liable for all shortages and losses. I understand that a reconciliation and verification of the petty cash fund should be conducted on a regular basis.

Custodian Signature
__________________________________ Date _________________

Approved and embossed by the Senior Business Officer or their designee
__________________________________ Date _________________

Approved by the Office of the Treasurer
__________________________________ Date _________________

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