Custodian Fund Request Form

A form used to request custodian funds for Human Subjects Studies, Change Fund, and Petty Cash.

Custodian Fund Request Form (PDF)

How to complete the Custodian Fund Request Form

  1. Provide details about the requested fund. Based on your budget form, enter a positive amount for the total of the request. Enter the Account, Fund, Dept. ID, Prog. (Program), Project you want these expenditures to be charged to.
  2. Enter unique 7-digit Custodian Fund ID from original Custodian Fund Request Form. All custodian funds will start with NR, followed by the unique 7-digit Custodian Fund ID.
  3. Put an “X” in the “Type of Custodian Fund Request” section (i.e. Research Participant Study, Petty Cash, Change Fund, or Reloadable Debit Cards – Research Participant Study).
  4. Ensure that the IRB number is entered into the “IRB Approval No” box.
  5. Fill in the Start Date and End Date of the study under the “Time Period” section.
    1. For Temporary Request mark “X” 3 months or less.
    2. For Replenishable Bank Account or Reloadable Debit Card Account mark “X” 1 year or greater.
  6. Fill in the custodian name and check payable information. Check payable will most likely be the custodian of the study. Fill in the building name, address, city, and state underneath the custodian name and check payable lines.
  7. Leave the “If address is different[…]” boxes empty unless the check’s intended delegate or address is different than the custodian address.
  8. Complete the “For additional information call” section with the contact name and phone number.
  9. Under the “Description/Amount Requested” section, provide a description of how the advance will be used. Fill in the Research Participant Study title, IRB Approval No., IRB Begin Date, IRB End Date, and provide a description of the project. If the operation is a Petty Cash Fund, provide a description of the operation under the respective section. If the operation is a Change Fund, provide a description of the operation under the respective section. Include the amount of requested advance for each operation needed.
  10. Confirm/enter the total amount of advance(s) from all requested operations in the “Total Amount Requested” section.
  11. Form is signed by the custodian. A delegate signature is also required if the check is not payable to the custodian.


  1. Verify information on Steps 1-11.
  2. Department approver signs custodian fund accounting form.
  3. File original documents in department.
  4. Send copy(s) to the Dean’s/Division Office for approval.


Keep a copy of the Custodian Fund Agreement along with the Custodian Fund Request Form and Custodian Fund Budget Form for internal records.

Dean/Director’s Office

Keep a copy of Custodian Fund Agreement Form along with the Custodian Fund Request Form for internal records. Send original documents to Cash Management, 21 N. Park Street, Suite 5301.

Policy & Procedure

UW Policy 3012 – Custodian Fund Policy


Questions about this form can be sent to