PURCHASING CARD

Reconciliation Form

Complete and attach to your bank statement. Please be sure receipts are attached to the bank statement in the same order that they appear on the bank statement. Thanks!

Department _________________________________ Month/Year __________________

Account Number(s) Approved Amount Disputed Amount

_______________________

$___________

$__________

_______________________

$___________

$__________

_______________________

$___________

$__________

_______________________

$___________

$__________

_______________________

$___________

$__________

_______________________

$___________

$__________

Total

$___________

$__________

Statement Total

$_____________

Dept Administrator Approval Signature: _________________________ Date: _____________

PC - 3

This page is maintained by B. Ray and was last updated in August 2000.

Department _________________________________ Month/Year __________________

Account Number(s)	Approved Amount	Disputed Amount
_______________________	$___________	$__________
_______________________	$___________	$__________
_______________________	$___________	$__________
_______________________	$___________	$__________
_______________________	$___________	$__________
_______________________	$___________	$__________
Total	$___________	$__________

Statement Total	$_____________

Dept Administrator Approval Signature: _________________________ Date: _____________