APPENDIX Form SA-1 ................................................................................. Purchase Order Accounts Payable Voucher Form SA-2 ............................................................................................................................................. Check Form SA-3 ........................................................................................................................................... Receipt Form SA-4 ................................................................................................................................... Ticket Sales Form SA-5-1 .......................................................................................................................... Financial Report Form SA-5-2 ................................................................................................................... Cash Reconcilement Form SA-5-3 .......................................................................................... Detail or Receipts and Expenditures Form SA-5-4 .......................................... Bond of School Treasurer/Certificate of School Treasurer/Principal Form SA-6 .................................................................................................... School Extra-Curricular Account Form SA-7 ......................................................................................................................... Claim for Payment Form SA-8 ............................................................................................................. Summary Collection Form Form SA-9 ............................................................................................................. Accountable items Review Form TBR-1 .................................................................................................... Inventory of Rental Textbooks Form TBR-2 ..................................................................... Official Receipts – Individual Textbook Rental List Form SF-1 .......................................... School Food Service Certification of Meals provided Per Home Rule Form SF-2 .................................................................. School Food Service Daily Record of Cash Received Form SF-2 A ............................................................ School Food Service Daily record of Meals/Mild Served Form SF-3 ................................................................................... School Food Service Cash Disbursements Form SF-4 ........................................ School Food Service ledger of Receipts, Disbursements and Balance Form SF-5 .............................................................................................. School Food Service Ticket Control Form SF-6 ................................................................................... School Food Service Equipment Inventory Form SF-7 ............................................................................................. School Food Service Food Inventory General Form 101 .................................................................................................................... Mileage Claim General Form 350 ..................................................................................................... Register of Investments General Form 370 ................................................................................................................ Receipt Register

FORM NO. SA-1 (Original)

Prescribed by State Board of Accounts Form SA-1 (Revised 2001)

PURCHASE ORDERACCOUNTS PAYABLE VOUCHER

No. __________________

SCHOOL EXTRA-CURRICULAR ACCOUNT

PAID BY CHECK: DATENo. _____________________ Date _______________________, _____Purchased From AddressPurchased For Deliver To Send Invoice To

TO THE DISBURSING OFFICER:

The following expense is proposed, payable from the ____________________________________ Fund.

Quantity Description Unit Price Total

Total This Order

Signed: _______________________________________ Person Authorized to Purchase

Date: ____________________, ____

Treasurer

An invoice or bill to be properly itemized must show: kind of service, where performed, dates service rendered, bywhom, rates per day, number of hours, rate per hour, number of units, price per unit, etc.

I hereby certify that there is an unobligated balance in theapplicable fund sufficient to pay the above order.

FORM NO. SA-1 (Duplicate)

Prescribed by State Board of Accounts Form SA-1 (Revised 2001)

PURCHASE ORDERACCOUNTS PAYABLE VOUCHER

(Receiving Copy)No. __________________

SCHOOL EXTRA-CURRICULAR ACCOUNT

PAID BY CHECK: DATE No. _____________________ Date _______________________, _____Purchased From AddressPurchased For Deliver To Send Invoice To

TO THE DISBURSING OFFICER:

The following expense is proposed, payable from the ____________________________________ Fund.

No payment is to be made for this order until the SA-1 Form is properly filed and the items have been received.

Quantity Description Unit Price Total

Total This Order

Signed: _______________________________________ Person Authorized to Purchase

Date: ____________________, ____

Treasurer

Date: ____________________, ____

Signed: _____________________________________ Signature

An invoice or bill to be properly itemized must show: kind of service, where performed, dates service rendered, bywhom, rates per day, number of hours, rate per hour, number of units, price per unit, etc.

I hereby certify that the attached invoice(s), or bill(s), is(are) true and correct and that the materials or servicesitemized thereon for which charge is made wereordered and received except.

I hereby certify that there is an unobligated balance in theapplicable fund sufficient to pay the above order

FORM NO. SA-1 (Triplicate)

Prescribed by State Board of Accounts Form SA-1 (Revised 2001)

PURCHASE ORDERACCOUNTS PAYABLE VOUCHER

(File Copy)No. __________________

SCHOOL EXTRA-CURRICULAR ACCOUNT

PAID BY CHECK: DATENo. _____________________ Date _______________________, _____Purchased From AddressPurchased For Deliver To Send Invoice To

TO THE DISBURSING OFFICER:

The following expense is proposed, payable from the ____________________________________ Fund.

No payment is to be made for this order until the SA-1 Form is properly filed and the items have been received.

Quantity Description Unit Price Total

Total This Order

Signed: _______________________________________ Person Authorized to Purchase

Date: ____________________, ____

Treasurer

Date: ____________________, ____ Date: ____________________, ____

Signed: _____________________________________ _______________________________________________ Signature Treasurer

An invoice or bill to be properly itemized must show: kind of service, where performed, dates service rendered, bywhom, rates per day, number of hours, rate per hour, number of units, price per unit, etc.

I hereby certify that there is an unobligated balance in theapplicable fund sufficient to pay the above order

I hereby certify that the attached invoice(s), or bill(s), is(are) true and correct and I have audited same inaccordance with IC 5-11-10-1.6.

I hereby certify that the attached invoice(s), or bill(s), is(are) true and correct and that the materials or servicesitemized thereon for which charge is made wereordered and received except ____________________.

Prescribed Form SA 2 (Rev 1970)

CHECK

HRS GROSS FEDERAL SOCIAL STATE PERIOD EMPLOYEEWORKED PAY WITH.TAX SECURITY WITH.TAX INSURANCE ENDING DETACH

BEFORECASHING

PRESCRIBED BY STATE BOARD OF ACCOUNTS FORM No. SA-2 (Rev. 1970)

SCHOOL EXTRA-CURRICULAR ACCOUNT ______________ (NAME OF SCHOOL) _______________ No. _____________________

Fund ____________________Purpose _________________ ______________________, Indiana ___________________, ____P.O. No. ________________Claim No. _______________ Pay to theInvoice No. _____________ order of _____________________________________________________ $ _______________________

___________________________________________________________________________ DollarsPayable atPayable at (Bank)

___________________________ ___________________________Superintendent or Principal Treasurer

SPACE FOR M.I.C.R.

ORIGINAL

HRS GROSS FEDERAL SOCIAL STATE PERIOD EMPLOYEEHRS GROSS FEDERAL SOCIAL STATE PERIOD EMPLOYEEWORKED PAY WITH.TAX SECURITY WITH.TAX INSURANCE ENDING DETACH

BEFORECASHING

PRESCRIBED BY STATE BOARD OF ACCOUNTS FORM No. SA-2 (Rev. 1970)

SCHOOL EXTRA-CURRICULAR ACCOUNT ______________ (NAME OF SCHOOL) _______________ No. _____________________

Fund ____________________Purpose _________________ ______________________, Indiana ___________________, ____P.O. No. ________________Claim No. _______________ Pay to theInvoice No. _____________ order of _____________________________________________________ $ _______________________

___________________________________________________________________________ DollarsPayable at (Bank)

NON - NEGOTIABLE

SPACE FOR M.I.C.R.

DUPLICATE

Combination form for payroll use as well as accounts payable

Prescribed by State Board of Accounts Form No. SA-3 (Revised 1997)

RECEIPTSCHOOL EXTRA-CURRICULAR ACCOUNT

SCHOOL__________________________________No.

_________________________, IN ____________________, _____

Payment Type and AmountCredit Card/

Cash Check/Draft MO Bank Card EFTAmount Amount Amount Amount Amount Other

RECEIVED FROM $

THE SUM OF DOLLARSTHE SUM OF DOLLARS

FOR DEPOSIT TO THE CREDIT OF FUND(Activity)

SOURCE

TREASURER

ORIGINALORIGINAL

Prescribed by State Board of Accounts Form No. SA-3 (Revised 1997)

RECEIPTSCHOOL EXTRA-CURRICULAR ACCOUNT

SCHOOL__________________________________ SCHOOLNo.

_________________________, IN ____________________, _____

Payment Type and AmountCredit Card/

Cash Check/Draft MO Bank Card EFTAmount Amount Amount Amount Amount Other

RECEIVED FROM $

THE SUM OF DOLLARS

FOR DEPOSIT TO THE CREDIT OF FUND(Activity)

SOURCE

TREASURER

DUPLICATE

(Form SA-4) Prescribed by State Board of Accounts No

TICKET SALES

SCHOOL TOWN OR CITYGAME DATEOTHER ACTIVITY

TICKETSTOTALTOTAL

KIND ISSUED RETURNED TICKETS PRICE AMOUNTSERIAL NO. AMT. SERIAL NO. AMT. SOLD SALES

TOTAL

Made by Verified and Approved by (Title) (Official or Sponsor)

ORIGINAL

(Form SA-4) Prescribed by State Board of Accounts No

TICKET SALES

SCHOOL TOWN OR CITYSCHOOL TOWN OR CITYGAME DATEOTHER ACTIVITY

TICKETSTOTAL

KIND ISSUED RETURNED TICKETS PRICE AMOUNTSERIAL NO. AMT. SERIAL NO. AMT. SOLD SALES

TOTAL

Made by Verified and Approved by (Title) (Official or Sponsor)

DUPLICATE

Form Prescribed by State Board of Accounts Form SA5-1

FINANCIAL REPORTSCHOOL EXTRA-CURRICULAR ACCOUNT

School ____________________________SCHEDULE OF BALANCES

RECEIPTS AND EXPENDITURES OFSCHOOL EXTRA-CURRICULAR ACCOUNT

From _____________________________________, ____

To _______________________________________, ____

BALANCE RECEIPTS BALANCEBEGINNING DURING END OF

NAME OF FUND OF PERIOD PERIOD EXPENDITURES PERIOD1 2 3 4

$ $ $ $

TOTAL ALL FUNDS $ $ $ $

Form Prescribed by State Board of Accounts FORM SA-5-2

CASH RECONCILEMENT

LOCATION

DEPOSITORY BALANCE ________ $

CASH ON HAND (ADD)

TOTAL CASH ON HAND AND IN DEPOSITORY $

TOTAL OF OUTSTANDING CHECKS (DEDUCT) $

BALANCEBALANCE ________

OUTSTANDING CHECKS_______________________________, ____

DATE NUMBER AMOUNT DATE NUMBER AMOUNT

$ BROUGHT FORWARD $

CARRIED FORWARD $ TOTAL $

Form Prescribed by State Board of Accounts FORM SA5-3

DETAIL OF RECEIPTS AND EXPENDITURESBY FUNDS

_____________________________________ FUNDRECEIPTS

SOURCE OF RECEIPTS NATURE OF RECEIPTS AMOUNT $

TOTAL RECEIPTS $

NOTE: TOTAL RECEIPTS MUST AGREE WITH RECEIPTS OF THIS FUND AS SHOWN IN COLUMN 2, PAGE 1.

EXPENDITURE

PURPOSE OF EXPENDITURE AMOUNT $

TOTAL EXPENDITURES $

Prescribed by State Board of Accounts Form SA5-4

The bank in which all moneys of this account are deposited is:

Name of Bank______________________________________________________________

Date school officially closed ___________________________, _____

BOND OF SCHOOL TREASURER

Location of Bank______________________________________________________________

BOND OF SCHOOL TREASURER

Name of Surety __________________________________________Amount of Bond $_______________________Date of Expiration ___________________________________, ____

CERTIFICATE OF SCHOOL TREASURER/PRINCIPALCERTIFICATE OF SCHOOL TREASURER/PRINCIPAL

I, ___________________________________, Treasurer, _____________________________,Principal, of the _________________________________________________ School Extra-Curricular Account, hereby certify that the foregoing report of the said account is true and correct to the bestof my knowledge and belief. I further certify that copies of this report have been filed with theofficers designated by law to receive copies of said report.

Treasurer

PrincipalPrincipal

COPIES TO BE FILED AS FOLLOWS:

Township School: 1 copy to Township Trustee1 copy to County Superintendent

School Corporation: 1 copy to Board of School Trustees or Board of School Commissioners1 copy to Superintendent of Schools

Prescribed by State Board of Accounts Form SA-6 (Rev. 1970)

SCHOOL EXTRA-CURRICULAR ACCOUNT

__________________________________ FUND NO. ________________

RECEIPTOR RECEIPTS DISBURSEMENTS

DATE ITEM CHECK NO. ~ DEBIT CREDIT BALANCE

1 11 12 2 3 34 45 56 67 78 89 9

10 1011 1112 1213 1314 1414 1415 1516 1617 1718 1819 1920 2021 2122 2223 2324 2425 2526 2627 2727 2728 2829 2930 30

Prescribed by State Board of Accounts Form SA-7 (Revised 2001)

CLAIM FOR PAYMENT

No. __________________

SCHOOL EXTRA-CURRICULAR ACCOUNT

PAID BY CHECK: DATE No. _____________________ Date _______________________, _____Purchased From AddressPurchased ForDelivered To Invoice Handed To

TO THE DISBURSING OFFICER:

The following expense is proposed, payable from the ____________________________________ Fund.

No payment is to be made for this order until the SA-7 Form is properly filed and the items have been received.

Quantity Description Unit Price Total $

An invoice or bill to be properly itemized must show: kind of service, where performed, dates service rendered, by whom, rates per day, number of hours, rate per hour, number of units, price per unit, etc.

Total This Order $

Approved for Payment __________________________________Signature

I hereby certify that the attached invoice(s) or bill(s) is (are) true and correct and that the materials or services itemized thereon

Date ____________________, ____ Signed: ______________________________________________Signature

I hereby certify that the attached invoice(s), or bill(s), is (are) true and correct and that the materials or services itemized thereon for which charge is made were ordered and received except __________________________________________________

I hereby certify that the attached invoice(s), or bill(s), is (are) true and correct and I have audited same in accordance with IC 5-11-10-1.6.

Date ____________________, ____ ______________________________________________Treasurer

PRESCRIBED BY STATE BOARD OF ACCOUNTS FORM SA-8 (2010) Date: SUMMARY COLLECTION FORM NUMBER

School Deposit To: Time Frame of Fundraiser: (Fund) Reason for Receipts: (Fundraiser, Field Trip . . . .) Sponsor: , Title: (Please Print Name) RECEIPT DETAIL: CASH: Coin: CHECKS: (See Detail Below) Money Orders: (See Detail Below) TOTAL: NOTE: All receipts for deposit must be accurately counted before turning in to the Treasurer. Any summary found to have a discrepancy will be returned. Please face bills and roll change when possible. The Extra-Curricular Treasurer is to provide an Official Receipt, Form SA-3, at the time the Summary Collection Form is turned in. I CERTIFY I HAVE ACCURATELY ACCOUNTED FOR ALL FUNDS AND REPORTED THE SAME HEREIN (Signature of Fund Representative, Name is Printed Above) Detail Checks/Money Orders (Attach Additional Information As Needed)

Amount From Additional Sheets $ Grand Total $

N u m b e r A m o u n t N u m b e r A m o u n t N u m b e r A m o u n t N u m b e r A m o u n t

S u b t o t a l $ S u b t o t a l $ S u b t o t a l $ S u b t o t a l $

PRESCRIBED BY STATE BOARD OF ACCOUNTS FORM SA-9 (2005) Date: ACCOUNTABLE ITEMS REVIEW Number:

School Time Frame of Report: DESCRIPTION: Beginning Inventory Purchases Subtotal Complimentary Distributions Per School Board Policy: Athletic Teams Staff Meetings Awards Other Total ( ) Total Eligible for Sale Ending Inventory ( ) Items Sold Sale Price $ Projected Revenue (Items Sold @ Sale Price) $ Actual Amount Received $ Difference $ Signed: Title:

Prescribed by State Board of Accounts Form TBR-1

INVENTORY OF RENTAL TEXTBOOKS

_____________________, ____ __________________________________________ Date Name of School or School Corporation

NAME OFNAME OFPUBLISHING NAME OF TEXTBOOK OR RETAIL TOTALCOMPANY SERIES OF TEXTBOOKS QUANTITY PRICE VALUE

Form Prescribed by State Board of Accounts School Form No. TBR-2 (Rev. 1997)

OFFICIAL RECEIPTS - INDIVIDUAL TEXTBOOK RENTAL LISTOFFICIAL RECEIPTS INDIVIDUAL TEXTBOOK RENTAL LIST____________________________________ SCHOOL, ________________________, INDIANA

Receipt 0001

Date Name of Student GradePayment Type and Amount

Credit Card/Cash Check/Draft MO Bank Card EFT

Amount Amount Amount Amount Amount Other

TotalQuantity Description - Name - Series - Code Unit Price Rental Fee For Use of Issuing OfficerQuantity Description Name Series Code Unit Price Rental Fee For Use of Issuing Officer

Total Received $ $

NOTE TO STUDENTS AND PARENTS:Care should be exercised in the use of rented textbooks in order that all books may be returned at the close of the school term in useable condition. For each textbook lost or returned damaged beyond use, an additional charge may be made as determined by school officials. Items available for classroom use not issued to students shall also be listed. If the volume of transactions for grades with a fixed list of books and materials is great enough to demand it, a copy of the printed list may be attached to the TBR-2 form and the form processed with a reference to such attached list instead of further itemization.

________________________________________________________ Issuing Officer

SF 1SF - 1SCHOOL FOOD SERVICE

School _____________________________ CERTIFICATION OF MEALS PROVIDED PER HOME RULE Date _____________________, _____

DAY OF MONTH MEAL PROVIDEDNAME/POSITION 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

TOTAL THIS PAGE

I certify that the above named individuals received meals on the dates designated in accordance with written School Board Policy.

Authorized Signature

Form Prescribed by State Board of Accounts School Form SF-2 (Revised 1998)

SCHOOL FOOD SERVICEDAILY RECORD OF CASH RECEIVED

School ___________________________________

CASH RECEIVED FOR FEDERAL

DATE TOTAL LUNCH OTHER RECEIPTS BREAKFAST KIND. STUDENT ADULT PREPAID PREPAID STATE REIMBURSEMENTSCASH SPECIAL ALA ALA PREPAID FOOD FOOD MATCHLI

NE

LIN

E

CASH SPECIAL ALA ALA PREPAID FOOD FOOD MATCH No ____ RECEIPTS STUDENT ADULT STUDENT ADULT MILK CARTE CARTE FOOD APPLIED TRUST FUNDS PROGRAM AMOUNT No

1 12 23 34 45 56 67 78 89 9

L L

10 1011 1112 1213 1314 1415 1516 1617 1718 1819 1920 2021 2121 2122 2223 2324 2425 2526 2627 2728 2829 2930 3031 3132 3232 32

TOTALS

F P ib d b St t B d f A t S h l F SF 2A (R i d 1998)Form Prescribed by State Board of Accounts School Form SF-2A (Revised 1998)

SCHOOL FOOD SERVICESF-2A DAILY RECORD OF MEALS/MILK SERVED School _____________________________________

NSLP AFTER SCHOOL SUP. SBPNumber of Meals Served Number of Meals Served Number of Meals Served Kindergarten

Date to Students Paid SF-1 Total To Students Adult SF-1 Total To Students Adult SF-1 Total Special MilkAdult Other NSLP Paid Other SUP Paid Other SBP

No _____ Paid Free Redu. Total Meals Meals Meals Paid Free Redu. Total Meals Meals Meals Paid Free Redu. Total Meals Meals Meals Paid Free Total No

1 1

LIN

E

LIN

E

1 12 23 34 45 56 67 78 89 9

10 1010 1011 1112 1213 1314 1415 1516 1617 1718 1819 1920 2021 2122 2223 2324 2425 2526 2627 2728 2829 2929 2930 30

TOTALS 31

Date ______________________________________ Signature _____________________________________

Form Prescribed by State Board of Accounts School Form SF-3 (Revised 1998)

SCHOOL FOOD SERVICECASH DISBURSEMENTS

School__________________________________________________

DISBURSEMENTS FOR

Labor - Labor -Service Food PREPAID AVAILABLE

Date Check Vendor/ Area Prep. & Equip Equip Misc/ Description of TOTAL FOOD CASHNo Number Description Food Direction Dispensing Purchase Repairs Other Misc/Other Expense DISBURSED TRUST BALANCE BALANCE No

LIN

E

LIN

E

SCHOOL FOOD SERVICE

No ____ Number Description Food Direction Dispensing Purchase Repairs Other Misc/Other Expense DISBURSED TRUST BALANCE BALANCE No

1 12 23 34 45 56 67 78 89 99 9

10 1011 1112 1213 1314 1415 1516 1617 1718 1819 1920 2021 2122 2223 2324 2425 2526 2627 2728 2828 2829 2930 3031 3132 32

TOTALS

Form Prescribed by State Board of Accounts School Form SF-4 (Revised 1998)

SCHOOL FOOD SERVICELEDGER OF RECEIPTS, DISBURSEMENTS AND BALANCE

School ______________________________________________________

CASH RECEIPTS CASH DISBURSEMENTS

MONTH TOTAL SERVICE FOOD PREPAID AVAILABLENE

NE

CASH SALES TO SALES TO STATE FEDERAL OTHER TOTAL AREA PREP. & FOOD CASH No _____ RECEIPTS STUDENTS ADULTS MATCH REIMB. RECEIPTS DISBURSEMENTS FOOD DIRECTION DISPEN. EQUIPMENT OTHER TRUST BALANCE BALANCE No

1 12 23 34 45 56 67 78 89 9

LIN

LIN

9 910 1011 1112 1213 1314 1415 1516 1617 1718 1819 1920 2020 2021 2122 2223 2324 2425 2526 2627 2728 2829 2930 3031 3132 3233 33

SF-5 SCHOOL FOOD SERVICE TICKET CONTROL

_______________________________Type of Ticket

School __________________________________________ School Year __________________

Ticket Numbers School Date Signature

SF-6 Page ____ of ____SCHOOL FOOD SERVICEEQUIPMENT INVENTORY

SCHOOL __________________________________________________ Date ___________________________

PURCHASE MODEL ORITEM / DESCRIPTION QUANTITY DATE BRAND NAME SERIAL NUMBER COSTITEM / DESCRIPTION QUANTITY DATE BRAND NAME SERIAL NUMBER COST

SF-7 Page ____ of ____SCHOOL FOOD SERVICE

FOOD INVENTORY

School ___________________________________________ Beginning Inventory $_______________Date Ending Inventory $Date ___________________________________________ Ending Inventory $_______________

Item Description Unit Size No. Units Unit Cost Total Value

Prescribed by State Board of Accounts General Form No. 101 ( 1955)

TO(GOVERNMENTAL UNIT)

________________________________________________ ON ACCOUNT OF APPROPRIATION NO. _____ FOR ___________________________(OFFICE, BOARD, DEPARTMENT OR INSTITUTION)

FROM TO SPEEDOMETER AUTO MILEAGEDATE READING+ MILES @_______¢

20 POINT POINT START FINISH NATURE OF BUSINESS TRAVELED PER MILE

MILEAGE CLAIM

AUTO LICENSE NO. TOTALS

+SPEEDOMETER READING columns are to be used only when distance between points cannot be determined by fixed mileage or official highway map.

Pursuant to the provisions and penalties of Chapter 155, Acts 1953, I hereby certify that the foregoing account is just and correct, that the amount claimed is legally due, after allowing all just credits and that no part of the same has been paid.

Date

Claim No. __________ Warrant No. ____________ I have examined the within claim and hereby certify as follows:

IN FAVOR OF That it is in proper form. That it is duly authenticated as required by law. That it is based upon statutory authority.

correct. That it is apparently

incorrect.

On Account of Appropriation No. ____________________________ for Disbursing Officer

Allowed ____________________________________________, 20____

$_______________

I certifytherein item

izw

as necessaaccordance w

{

(Board or Commission)

FILED

(Official Title)

In the sum of $_______________

y that the within bill is true and correct; that the m

ileage zed and for w

hich charge is made w

as ordered by me and

ary to the public business; and that the rate per mile is in

with statutes or governing ordinances, except

Prescribed by State Board of Accounts General Form No. 350(1964)

REGISTER OF INVESTMENTSName of Unit Fund

(USE SEPARATE SHEET(S) FOR EACH INVESTMENT FUND. LIST EACH SECURITY INDIVIDUALLY.)

INTERESTDate Nature SAFEKEEPING RECEIPT Rate AMOUNT PAID Date AMOUNT RECEIVED EARNED RECEIVED

of of Serial Maturity of Maturity Accrued Sold or TotalPurchase Investment No. Issued By No. Date Interest Value Principal Interest Total Paid Redeemed Principal Interest Received Date Amount Date Amount

Interest Earned for Each Investment Rate of Number of Days from Date of (Investments purchased and then either sold or redeemed in the same calendar yearon Hand at December 31. - Calculated By: Multiply: Interest Principal X (Times) Purchase to December 31 Divided By: 360 (Days) don't need a calculation because interest earned equals interest received.)

Prescribed by State Board of Accounts General Form 370 (1997)

______________________________________________________________________G t l U itGovernmental Unit

RECEIPT REGISTERPayment Type and Amount

Credit Card/Receipt Receipt Receipt Cash Check/Draft MO Bank Card EFT

Date Number Amount Received From Fund Description Amount Amount Amount Amount Amount Other

TOTAL