New Custodial Fund Agreement

Indiana University Form No. A-119 (Revised 9/09)	Name of Custodian (please print) _____________________________________________________
	Amount of Custodial Fund Requested: $ _________________________

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General Information
Department:____________________________________ Custodian Address:______________________________ Custodian Phone:   ______________________________ Custodian Email:     _____________________________		Campus: __________________ Contact Person Name: ___________________________ Contact Person Phone: ____________________________ Contact Person Email: ____________________________
Account Number used for recording expenses: _________________ Account Number for Receivable (if known): ____________________
Fund Information
Type of Fund:	____ Change Fund	____ Petty Cash Fund
	____ Revolving Fund	____ Bank Clearing Fund
Purpose of Custodial Fund:  ___________________________________________________________
___________________________________________________________
Secure location the funds are kept: _______________________________________________________
If funds are kept in a bank account, please provide the following information:
Bank Name: _______________________ Account Number: last 4 digits only__________
As Custodian of this fund, I agree to accept the responsibility for the protection and proper use of this fund. I understand that I am covered by the university's Blanket Bond and that I will be held personally liable for losses except loss by theft if it is reported at once and the police investigation absolves me of negligence.
To terminate my custodianship of this fund, I agree to contact FMS - Bank Reconciliation (or IUPUI Accounting Records and Services) for specific instruction.  In no event will I transfer or assign these funds to my successor without submission of another signed agreement containing the appropriate signatures and approved by FMS or IUPUI Accounting.
I have read and agree to abide by Indiana University Policy I-560. I will submit written justification for the continued need for these funds on an annual basis to the Custodial Fund Coordinator in Financial Management Services.
Signature of Custodian: _____________________________		Date: ____________
Approval of Account Manager: _______________________		Date: ____________
Approval of Fiscal Officer: _____________________________		Date: ____________
Approval of C&G Analyst: ____________________________ (if grant account is to be used for expenses)		Date: ____________
* DO NOT use this agreement if changing the custodian responsible for an existing fund *
This section for Financial Management Services and IUPUI Accounting Records and Services use only
Payee ID: __________________________________ DV Doc #: __________________________________		Doc Date: ______________
Custodial Fund Manager Approval: _________________________		Approval Date: ______________