Missing Receipt Form Sample
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
Cardholder Name: Telephone Number:Phone:
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
• Cardholder acknowledges that repeated lack of documentation could result in
revocation of his or her P-Card.
Cardholder Signature: ___________________________________Date: ______________
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)