LOS ANGELES UNIFIED SCHOOL DISTRICT

Accounting and Disbursements Division

IMPREST FUND REQUEST FORM

Imprest Request Type:
Establish Account	Increase Account	Close Account Submit the following documents to Accounts Payable: Final claim A check of unspent funds payable to LAUSD Bank reconciliation report Bank statement
Amount:	Amount:	From	To
Maximum amount: $750 (Office) School amount varies. Refer to Section II of Imprest Fund Reference Guide	Maximum amount: $5,000 (School) $20,000 (Educational Service Center) $2,000 (Other office)
School Enrollment:	Budget Adjust. Document No:
My school has a Specially-Funded Program Two or more schools are under my direct supervision	____________________________________________
Requestor/Administrator Details:
Last Name:	First Name:	MI:	Title:	Employee #:
School/Office:	Cost Center:	Vendor Account:	Phone:	Email:
I agree that upon receipt of funds or endorsement of the warrant, I will be personally responsible for the money furnished for my Imprest fund, and I accept financial responsibility for any unauthorized or un-reconciled expenditures. At the end of each quarter, I will submit copies of the bank and fund reconciliations to my Educational Service Center Fiscal Specialist (school). I understand that the additional amount has been deducted from my office’s general supply account or school’s General Fund School Program budget program and that it is a one-time reduction in this account. If I leave the Los Angeles Unified School District for any reason, or if I am reassigned, I agree to close my account by submitting a final claim for all purchases made, returning all unspent funds, and ensuring the proper and immediate transfer of the bank account to the incoming Administrator. I understand that, at all times, the total of outstanding supporting authorized purchases and unspent funds must equal the total amount of my Imprest Fund.
Administrator’s Signature	Date
Accounts Payable Use:
Received:	Approved by:	Date: