ADMINISTRATIVE FORM 3504 ADMINISTRATIVE FORM 3504

STUDENT ACTIVITY FUNDS STUDENT ACTIVITY FUNDS

CASH COUNT SLIP CASH COUNT SLIP

Date Receipt # Date Receipt #

Account Account

Source description Source description

Currency # of items Currency # of items

100$ 100$

50$ 50$

20$ 20$

10$ 10$

5$ 5$

2$ 2$

1$ 1$

Deposited by Deposited byDate Date

Verified by Verified byDate Date

Extended amount Extended amount

Total currency Total currency

Signature Signature

Total receipts Total receipts

School name School name

Signature Signature

Total coin Total coin

Total checks Total checks