Accounts Receivable Return Deposit Item Processing Form

200 Piedmont Avenue, Suite 1604 West Tower, Atlanta, GA 30334 Phone (404) 656-2133, Fax (404) 463-5089

Requesting Agency Name:

Agency PeopleSoft Business Unit:

Date Requested:

Requested by:

Phone Number:

Requestor's Email Address:

TRANSACTION INFORMATION

Statement Code:

Statement ID:

Transaction Amount:

Bank Date:

Brief Description of Reconciling Entry:

Authorized Approver

By selecting this box, I certify I am authorized approver, on behalf of my agency, to submit this Accounts Receivable Return Deposit Item Processing Form to the State Accounting Office. I further acknowledge the voucher information entered is true in nature.

State Accounting Office Use Only

Processed By SAO:

Date:

Issue Number:

SAO Form: 100-D

Indicates Response Required