Petty Cash Log Template

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Petty Cash Log
Date of Request:
Check Payable To:
Mail Check to:
$
Beginning Cash
(Ending cash on hand from last Petty Cash Log)
+
Checks Received from OSI (Petty Cash reimbursement checks received since last Petty Cash Log submission)
-
Cash Paid Out (Amount of this request)
$
Ending Cash (Beginning cash on hand on next Petty Cash Log - Should equal actual cash on hand)
Date of
Office
Receipt
Brief
Amount
AP Code
Receipt
to Charge
Name
Description
(office use only)
Submitted by:
Doctor's Signature:
Note: All original receipts must be attached and form must be signed prior to processing.

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