Fillable Printable Missing Receipt Form Sample

Missing Receipt Form Sample

P-CARD PROGRAM

MISSING DOCUMENT AFFIDAVIT

This form should be completed for any P-Card transaction that does NOT have documentation

from the merchant. This should be provided to Supervisor/Budget Head as part of budget cycle

reconciliation paperwork.

Cardholder Name: Telephone Number: Phone:

Department:

Vendor/Merchant Name:

Transaction Date (month/day/year):

Transaction Amount (Total Cost):

Description/Quantity/Cost Per Item/Total Cost: (Add an additional sheet if necessary):

Reason Original Documentation is Not Available

Cardholder Certification Signature:

I attest the information provided is true and an accurate description of the details of the

purchase. I confirm that every attempt to obtain a duplicate receipt by contacting the vendor has

been made, but have been unable to do so and also hereby certify the following:

• All items purchased on this P-Card transaction were for Delgado Community

College use. No personal purchases were made.

• The Cardholder will not seek reimbursement from the Delgado Community

College in any other manner for this transaction.

• Original documentation is not in Cardholder’s possession for the reasons stated

above.

• Cardholder acknowledges that repeated lack of documentation could result in

revocation of his or her P-Card.

Cardholder Signature: ___________________________________ Date: ______________

Supervisor/Budget Head:

I have accepted the cardholder’s explanation of the loss and inability to obtain a duplicate receipt;

therefore, I am authorizing payment of the receipt or invoice in light of the circumstances involved.

Supervisor/Budget Head Print Name:

Supervisor/ Budget Head Signature: ________________________________ Date: __________

Form 3300/012 (7/12)