Lost/missing Receipts Form Department Of Health And Hospitals Office Of Payment Management
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1Lost/Missing Receipts Form
Department of Health and Hospitals
Office of Payment Management
Certification of Unavailable Documentation:
This form should be completed for any purchase that does NOT have the original documentation from the merchant. This
form shall be completed and attached to your DHH TE Form.
Name of Traveler: ___________________________________________________________________________________
Telephone Number: ________________________
Department Name: _______________________________________
Merchant Name: ____________________________________________________________________________________
Transaction Date (mm/dd/yyyy):______________________ Transaction Amount (Total Cost): $_________________
How did you pay for this purchase? ___ Cash ___ Debit/Credit Card (A copy of your statement with the purchase
highlighted must be submitted to receive reimbursement.)
Description
Quantity
Cost per Item
Total Cost per Line
(Add an additional sheet if necessary)
________________________________________
________
____________
_______________
________________________________________
________
____________
_______________
Reason Original Documentation/Receipt is Not Available:
___________________________________________________________________________________________________
Traveler Certification:
I attest the information provided is a true and accurate description of the details of this purchase. I confirm that every
attempt to obtain a duplicate receipt by from the merchant has been made, but have been unable to do so and also hereby
certify the following:
•
All items purchased were for official DHH use. No personal purchases were made.
•
The Traveler will not seek reimbursement from DHH in any other manner for this transaction.
•
Original documentation is not in the Traveler’s possession for the reasons stated above.
Traveler Name: _____________________________________________________________
Date: ______________
Signature: __________________________________________________________________
Supervisor Certification:
I have accepted the Traveler’s explanation for the missing documentation and inability to obtain a duplicate receipt;
therefore, I am authorizing payment of the lost/missing receipt or invoice.
Supervisor Name: ____________________________________________________________
Date: ______________
Signature:___________________________________________________________________
Department Head Approval:
I am authorizing payment of the lost/missing receipt or invoice.
Department Name: ___________________________________________________________
Date: ______________
Signature:___________________________________________________________________
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