Chapter Bank Reconciliation Form

Step 1 - Obtain or create electronic copies of all 3 bank statements
(must be in pdf. format)
Step 2 - Complete the Cash Disbursements Form (if the chapter paid out any money).
Step 3 - Complete the Cash Receipts Form (if the chapter received any money, including interest).

Step 4 - Complete the Bank Reconciliation Form (mandatory).

Important! You must have your bank statements available, for reference, to help complete this form.

Chapter Information

Chapter Name : *
please spell out the full chapter name
Chapter Financial Code : *
four digit number that begins with 4_ _ _
Bank Name: *
Account Type: *
Fiscal Year (July 1, 2013 - June 30, 2014):
Quarter: *
Month(s): *
Prepared By: *
Email Address: *

Bank Account

(Format for dollar amounts should be 1200.00)

Ending balance shown on the bank statement (For the individual month OR the last month of the quarter): *
Date of Statement : *

Add deposits made, but NOT shown on current statement

Outstanding Deposit Total:

Subtract checks written, but NOT shown on current statement

Outstanding Checks Total:
Adjusted bank balance:
Must agree with balance, per books, at month end or quarter end

Supporting Documents

Please check one:

Account Activity - Chapter DID have Cash Receipts and/or Cash Disbursements for this reporting period (attached below):
No Account Activity - No Cash Receipts or Cash Disbursements to report:

The Cash Receipts and Cash Disbursement Forms can be attached to this form one of two ways. Attach one completed form for each month of the quarter OR attach one completed form that includes information for all three months of the quarter.

Attach Cash Disbursements Form (Month 1):
Attach Cash Receipts Form (Month 1):
Attach Cash Disbursements Form (Month 2):
Attach Cash Receipts Form (Month 2):
Attach Cash Disbursements Form (Month 3):
Attach Cash Receipts Form (Month 3):
Attach Cash Disbursements Form (All 3 months):
Attach Cash Receipts Form (All 3 months):

Bank Statements are mandatory:

Attach Bank Statement (Month 1):
Attach Bank Statement (Month 2):
Attach Bank Statement (Month 3):
Attach Bank Statements (All 3 months):

Further Comments:

Your Name: *
Your Email Address: *




revised 3/14

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