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