Custodian Fund Request Form Instructions
Do not use this form for travel , please refer to Policy: 302 Travel Advances (Including e-Reimbursement Travel Authorization and Cash Advance).
The Custodian Fund Request Form along with the Custodian Fund Agreement Form are used to request custodian funds for human subject studies, change of funds, petty cash and contingent bank accounts. See Custodian Fund User Guide.
Please attach this signed form to the Custodian Fund Agreement before sending it onto the Department for review and approval.
Custodian Fund are advanced only to authorized, permanent UW employees. The Custodian Funds are issued for a specific purpose and may not be used for any other purpose than expressed on the Custodian Fund Request Form.
All Custodian Funds must be reconciled monthly to authorized advance levels and properly accounted for within 30 days of the end of the advance period.
All Custodian Funds require quarterly reporting, regardless of activity, to ensure advance levels are maintained by using the Custodian Fund Accounting Form.
Fields |
Information Required |
|---|---|
Amount |
Leave blank – will auto fill based on the total for Itemized Expenditures |
Date |
Leave blank – will auto fill with current date |
| Account | 4-digit - leave Account Code as is 6167 (Custodian Cash Advance); Account Code Listing |
Fund |
3-digit fund or appropriation - Fund Listing |
| DeptID | 6-digit - Organization/Dept ID |
| Prog | 1-digit - Program Codes |
| Project | 7-digit |
Custodian Fund ID |
Enter unique 7-digit Custodian Fund ID from original Custodian Fund Request Form. All custodian funds will start with NR, followed by the unique 7-digit Custodian Fund ID. (See Custodian Fund User Guide for more info.) |
Check applicable boxes |
Check the appropriate box which apply to the Type of Custodian Fund request: ____ Human Subject Study ____ Contingent Bank Account ____ Change Fund ____ Petty Cash ____ 3 months or less ____ 1 year or greater (requires a set-up request for a UW-Madison bank account) |
Time Period Start Date: End Date: |
Enter the custodian fund account start date and the expected end date. Note: A Custodian Fund Accounting Form must be completed within 30 days after the end date of custodian fund request. If moneys are owed back, then a check for the amount due must be attached to the Custodian Fund Accounting Form. |
Custodian Name (Check payable to) : |
|
Custodian Name |
Full name of Custodian |
Check payable to |
If payable to bank account, use last five digits of bank account and the name of the bank account. If payable to other than the Custodian, enter the Department/Division Name. |
Building |
Building Name |
Address |
Street/PO address of Payee |
City, State/Zip |
Name of city, state, and zip of Payee |
To: (If different than the Custodian Address) |
|
Deliver to |
Full name of Deliver To person |
Building |
Building Name |
Address |
Street/PO address of Deliver To person |
City, State/Zip |
Name of city, state, and zip of Deliver To person |
For additional information call: (Name and Phone Number) |
|
Itemized Budget |
|
Human Subject Study |
Describe the project and the estimated cost. Under the Amount column, enter the total expected cost of the study, which will be included in this advance. |
| Contingent Bank Account | Set up by Cash Management and Division/Deans Offices only when deemed applicicable. |
| Change Fund | Departments involved in revenue producing activities which require coin/currency on hand for retail transactions. Describe the operation which is requesting a change fund. Under the Amount column, enter the total change fund being requested. |
Petty Cash Fund |
Set up by departments for handling small purchases when purchase cards and/or checks cannot be used. The petty cash fund is usually less than $100. Describe the operation which is requesting a petty cash fund. Under the Amount column, enter the total petty cash amount being requested. |
Total |
Leave blank – amount should auto-fill based on detail budget amounts above. |
Signature Information |
|
Date/Name of Custodian |
Current date and signature of Custodian requesting advance |
Department Approval |
Current date and signature of Department Approval. Print name of approver. |
Dean/Director Approval |
Current date and signature of Dean/Director Approval. Print name of approver. |
Send to |
After approvals are obtained send to: Cash Management, 21 N. Park Street, Suite 6101 |
Custodian/Department: Keep a copy of Custodian Fund Request Form along with the Custodial Fund Agreement for internal records.
Dean/Director's Office: Keep a copy of Custodian Fund Request Form along with the Custodian Fund Agreement for internal records. Send original documents to Cash Management, 21 N. Park Street, Suite 6101.
Custodian Fund Procedures:
Cash Management Contacts:
cstdnfnd@bussvc.wisc.edu