Free 14311.PDF - Indiana

REPORT OF COLLECTIONS / RECEIPTS (DUE TREASURER OF STATE)
State Form 14311 (R2 / 12-02)

FOR TREASURER USE ONLY

Approved by State Board of Accounts, 2002 Approved by Auditor of State, 2002

LINE NUMBER

FUND NUMBER

OBJECT

CENTER

AMOUNT

DESCRIPTION

GRAND TOTAL Currency Silver Checks Deposits Wire Transfers Lock Box Debts Credits ACH TOTAL Title

Prepared by:

Date prepared:

Preparer's telephone number

I certify that this report is true and correct to the best of my knowledge and belief.
Signatue of agency official or designee

Name of state agency

Agency number

DISTRIBUTION: White - Auditor of State; Canary - Agency after processing; Pink - Treasurer