Effective Date: 




Updated: 1/2013



To document the request, approval and disbursement of funds from Brenham State Supported Living Center petty cash funds.



When to Prepare

Form 4041-B is prepared when making a request for petty cash usage. With the exception of a reimbursement request, the form is prepared and submitted at least three business days in advance of the needed funds to ensure that approval signatures are obtained before the issue and receipt of the funds.

This form is used to request petty cash for the following reasons:

  • emergency payments and small purchases which will increase the efficiency of the operation;
  • resident outings not covered by other funds; and
  • reimbursement to employees who made payments for the reasons above.


A state supported living center department/division head authorized to approve petty cash disbursements must approve and sign the request, and forward the request to the center assistant director of administration (ADOA) or designee for approval. Note: The person approving the petty cash request must never be the person requesting the funds.

After all signatures and approvals are obtained, the funds are issued by the cashier. Receipt of the funds is acknowledged by signature on the form. The responsibility statement must be signed by the receiver every time petty cash is transferred from one employee to another.

Number of Copies

The original is kept with the cashier. A copy is provided to the requestor/unit representative who receives the funds. In the event that the funds are transferred to another employee before monies are used, an additional copy should be made and kept with the employee who distributes the funds to another employee.

Form Retention

The cashier retains the original form until it is sent to Regional Accounting for reimbursement. Regional Accounting must retain the original form per records retention standards.


Detailed Instructions

For Cashier Use When Funds Issued — The cashier enters the petty cash tracking number from the list of numbers maintained by the cashier's office, the amount issued, the date and the issuing cashier's name.

For Cashier Use When Funds Returned — The cashier enters the amount returned, the date, the actual amount spent and signs his/her name.

Charge Department No./Unit — Enter department and unit.

Date Needed — Enter the date when petty cash is needed.

Amount — Enter total amount requested.

Purpose of Petty Cash Withdrawal Request — Enter the purpose of the request.

Activity Date — Enter the date of the activity.

Requestor — Enter the name of the requestor.

Vendor Information (Must be obtained before withdrawal, when known.) — Enter the vendor ID number, vendor name, address, city/state/ZIP, area code and telephone number, if this information is known at the time of request.

Signature–Department/Division Head and Date — A department or division head must sign and date the form.

Signature–Asst. Director of Administration or Designee and Date — The ADOA or designee must sign and date the form.

Description of Supplies or Services — Provide a detailed description of the supplies or services requested.

Individuals Participating (if applicable) — For outing requests, enter the following information for each individual: case number, individual's full name, home, cash needed for each individual and cash returned. If additional information is needed, attach a trip sheet.

Responsibility Statement — Each staff member with custody of petty cash after it is distributed from the cashier's office must acknowledge his/her responsibility to safeguard the petty cash funds at all times by signing as the receiver.

Signature–Unit Representative Receiving Cash and Date — Self-explanatory.

Receiver, Amount and Date — Self-explanatory.

Signature–Witness Observing the Placement of Receipts and Change in Secured Lock Box and Date — If cash is returned after business hours, a witness must sign and date that unused funds and receipts are being placed in a secured lock box.

Employee Making Return and Amount — The employee making the return of petty cash and receipts must sign and record the amount of cash being returned.

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