Page 12 - GFSI-Cover Module 2

GREENTREE FOOD SOLUTIONS, INC.
CHANGE FUND ACCOUNTABILITY FORM

Date: _______________

Custodian: Employee ID:

Contact No.: Email Address:

Responsibility Center: Department

Current Fund Amount Amount:

Establishment of Change Fund Amount:
(Please provide justification)

P ________ increase of petty cash New Amount:

P ________ decrease of petty cash New Amount:

Change custodian FROM _________________________ TO ____________________________

Close Petty Cash Fund

I, __________________________ , hereby acknowledge that I am the custodian of the Change Fund
for _______________________, in the amount of _______________. These funds will be
maintained at _______________________________.

I understand that I am responsible for safeguarding and maintaining accountability for these funds
and agree to keep personal funds separate and apart from Change Fund. I understand that I must
submit Change Fund reconciliation to my supervisor for his/her signature.

I also acknowledge that these funds will solely be used only as change fund related to the store.

Upon my job reassignment or termination from this Company, I agree to return these funds to GFS –
Finance.

Custodian Name & Signature:

Requested by Department Head:
Approved by Division Head:

Approved by Finance Director: