Form Obm 4500 - Petty Cash Account Request -Ohio

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PETTY CASH ACCOUNT REQUEST
AGENCY REQUEST
OBM ACCOUNT ID
Send to:
NUMBER
NUMBER
obmpettycash@obm.ohio.gov
STATE AGENCY
OAKS BUSINESS
FUND
FISCAL
NAME
UNIT
STATUTORY AUTHORITY
CODE
YEAR
ORC 126:21 (A6)
The Director of the Office of Budget and Management is requested to authorize:
Establishment of a new petty cash account.
Increase in an existing petty cash account.
Authorized Amount before Request $_
______
(This will create a new OAKS Supplier ID)
EXISTING OAKS SUPPLIER ID IS:
_____
Explanation of Request:
Explanation of Request:
Describe below the purpose for establishing a
Provide justification below for an increase in an existing
new account. Include needed exceptions to OBM
account.
procedures for type or amount of purchases.
This request is for a:
General Use account (Small incidental purchases or change funds)
Special Use account (Requires exceptions for Security, Confidentiality, etc. described below)
A bank account will be used with some or all of this account
Yes
No
NAME OF ACCOUNT
LINE 1: Name of State Agency
LINE 2: Specific Petty Cash Name
(I.E., LAKE HOPE PETTY CASH ACCOUNT)
Custodian of Account
Name:
Phone: (
)
E-Mail Address:
Fax :
(
)
Location of Account
Street Address:
City:
State:
Zip Code:
Remittance Information: Indicate below the Remittance Address of your account. This address will appear on warrants.
Same as Location of Account
EFT (Electronic Funds Transfer)
Remit Street Address
City
State
Zip Code
Note: If EFT, must complete Form OBM -4310 (Rev.9/2015) Authorization Agreement for Direct Deposit of EFT Payments
I certify this account complies with OBM petty cash policies
Amount of New Acct / Increase
$
Requesting Director or Authorized Signature
Date
Request Approved
OAKS Supplier ID ___________
Director of the Office of Budget and Management
Date
Request Denied
OBM 4500 (4/2016)

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