Teacher Name: _________________________________________   Total Cash: $______________

Account Number:________________________________________   Total Checks: $____________

Collected for:___________________________________________   Total Deposit: $____________
 

	Check #	Student Name	Cash Total	Check Total	Waiver
1	#	___________________________	$	$	__________
2	#	___________________________	$	$	__________
3	#	___________________________	$	$	__________
4	#	___________________________	$	$	__________
5	#	___________________________	$	$	__________
6	#	___________________________	$	$	__________
7	#	___________________________	$	$	__________
8	#	___________________________	$	$	__________
9	#	___________________________	$	$	__________
10	#	___________________________	$	$	__________
11	#	___________________________	$	$	__________
12	#	___________________________	$	$	__________
13	#	___________________________	$	$	__________
14	#	___________________________	$	$	__________
15	#	___________________________	$	$	__________
16	#	___________________________	$	$	__________
17	#	___________________________	$	$	__________
18	#	___________________________	$	$	__________
19	#	___________________________	$	$	__________
20	#	___________________________	$	$	__________
21	#	___________________________	$	$	__________
22	#	___________________________	$	$	__________
23	#	___________________________	$	$	__________

Receipt Number ______________________

Teacher's Signature: ____________________________________ Date:__________________

Bookkeepers Signature: _________________________________________