Sf 211 - Reouest For Change Or Establishment Of Imprest Fund
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2MS 761
ATTACHMENT B
REQUEST FOR CHANGE OR ESTABLISHMENT OF IMPREST FUND
Aug. 2008
SF 211 (FRONT)
Standard Form 211 (2-82)
Department of the Treasury
I TERM 4-3000
REOUEST FOR CHANGE OR ESTABLISHMENT OF IMPREST FUND
SECTION I—IDENTIFICATION OF DISBURSING OFFICER AND CASHIER
NAME AND LOCATION OF DISBURSING OFFICE:
NAME OF CASHIER:
AGENCY:
ADDRESS:
PHONE NO.
SECTION II - ACTION REQUESTED
EFFECTIVE DATE ____________________________ .
Designation
Change to Alternate
Increase Advance
Liquidation
Revocation
Change to Principal
Decrease Advance
Address Change
Class Change
Olher (Explain)
SECTION III - DESIGNATION INFORMATION
Class and Type of Cashier (If Alternate - show name of Principal)
SECTION IV—INCREASE OR NEW ADVANCE
SECTION V - DECREASE OR LIQUIDATION OF FUNDS
Current Balance ............................................................. $ ________________
Current Balance .................................................................. $ ______________
Apply the following
Increase or New Advance Requested
......................... $ ________________
Reimbursement Voucher Nos:
Total .............................................................................. $ ________________
$ ______________
Number and Denomation of Checks Requested:
Uncashed Treasury Check Nos:
$ ______________
Deposit Ticket Nos:
$ ______________
Net Balance for Which Cashier is
Fund Transfer from:
Accuntable ......................................................................... .$ ______________
Date
Signature (Head of Agency or Designee)
Title
SECTION Vl—DESIGNATION (to be completed by Disbursing Officer)
In accordance with the provisions of paragraph 2 of section 4 of Executive Order 6166 of June 10, 1933 as amended the function of disbursing in
connection with the operations of the agency named is hereby delegated to the above-named employee effective on the date indicated below. Class D Cashiers
may use their funds for change making only. Class A and B cashiers may make payments in cash in accordnance with the Treasury Fiscal Requirements
Manual (I TFRM 4-3000) and such other payment as may be listed on the attached schedule.
________________________________________________________________
_____________________________________________________________
(Effective Date of Designation)
(Disbursing Office or Designee)
_______________________________________________
(Date – month day and year)
SECTION Vll - CHECK ISSUANCE AUTHORIZATION (to be completed by Disbursing Officer)
DRAW CHECKS AS INDICATED ABOVE
DATE CHECKS ________________________
______________________________________________________________
(DIsbursing Office or Designee)
CHECK NOS. ______________ TO _________________________________
______________________________________________________________
(Date – month day and year)
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