Missing Receipt Declaration Form - Berea College printable pdf download

MISSING RECEIPT DECLARATION

When a receipt is lost or otherwise unavailable and all measures to obtain a copy have been exhausted, this Missing Receipt

Declaration should be completed. It should be signed by the employee and the employee’s supervisor and submitted with the

employee’s reimbursement request, unless the transaction was placed on the employee’s Purchasing Card. In the case of a

Purchasing Card transaction, the Missing Receipt Declaration should be retained by the cardholder with all other receipts and

documentation. NOTE: A Missing Receipt Declaration is not required for gratuities.

I am missing a receipt for: _________________________________________________________________________________

Description of Transaction

I incurred the expense at: ________________________ on ____________________ for $______________________________

Supplier Name

Date

Expense Amount

The receipt was (check applicable):

Lost

Never Received

Other __________________________________________

The form of payment I used was:

Purchasing Card

Check

Cash

Personal Credit Card

Other __________________________________________

Business Purpose of Transaction:

_____________________________________________________________________________________

Persons Involved (if expense is related to travel or entertainment):

_____________________________________________________________________________________

I understand that a Missing Receipt Declaration should be used on rare occasions and may not be used on a routine basis. I

further understand that excessive use of a Missing Receipt Declaration may revoke the privilege of a providing a declaration in

lieu of a receipt.

I certify the amount shown is the amount I actually paid; that I have not and will not submit a duplicate claim; and that I have not

and will not seek a claim for these expenses from any other College source.

________________________________________

Employee Signature

Supervisor Signature

________________________________________

Employee Name Printed

Supervisor Name Printed

____________________________________

________________________________________

Date

Office of Financial Affairs, CPO 2206, Berea, KY 40404

Tel: (859) 985-3096 Fax: (859) 985-3615

Missing Receipt Declaration Form - Berea College