Please issue a FIS Check in the amount of $_______________* to replenish the Petty Cash Fund of:

Receipts are attached for all monies expended. A purpose for the expenditure must be included on each receipt. The expenditures should be charged as follows:

Expenditure Total $ ________________

* Total of expenditures must equal amount of FIS Check requested.

Supervisor’s Signature: ___________________________ Date _____________