Petty Cash Disbursement Voucher

Fields with * are required.

1. For reimbursement present completed form, original receipt(s), and CSULB ID Card to Cashier's Office Window located in Room 148 of Brotman Hall.

2. Receipt total must not exceed $50.00 exclusive of sales tax per transaction. Total Receipts for Reimbursement must not exceed $100.00.

3. Receipt total must match chartfield total.

4. Original receipts for purchases and/or parking must be attached and match line item amounts.

5. For mileage transactions, the transaction amount is calculated. Use CALCULATE button to display the calculated amount.

ORGANIZATION INFORMATION *Department
*Department Reference

TRANSACTION INFORMATION

TRANSACTION DATE TRANSACTION DATE Enter the date (MM/DD/YYYY ).	TRANSACTION TYPE TRANSACTION TYPE Enter V for Purchase, M for Mileage or P for Parking.	DESCRIPTION DESCRIPTION For Purchase, Enter a Detailed Description. For Mileage, Indicate Purpose of trip. For Parking, indicate Location.	MILES DRIVEN MILES DRIVEN If Transaction is Mileage, Enter Number Miles Driven.Use the calculate button to display mileage cost and total cost.	AMOUNT AMOUNT For purchases or parking,enter the amount.Use the calculate button to display mileage cost and total cost.
				$
				$
				$
				$
				$
				$
				$
			TOTAL	$

I hereby certify that this expenditure is necessary for the department's operations and the university's mission.

*EMPLOYEE NAME *EXTENSION

Employee Signature Date

*APPROVER NAME *EXTENSION

APPROVER Signature Date

I hereby authorize the designee, whose name is listed below, to pickup reimbursement.

DESIGNEE FOR PICKUP (NAME)

Employee Signature Date

$ Received by:

Signature

Date

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