Missing Receipt Declaration - Vermont Department Of Finance & Management
Download a blank fillable Missing Receipt Declaration - Vermont Department Of Finance & Management in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Missing Receipt Declaration - Vermont Department Of Finance & Management with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1Agency of Administration
Dept of Finance & Management
MISSING RECEIPT DECLARATION
Employee Travel & Expense Reimbursement
Purpose: If all measures to obtain a required missing receipt have been exhausted, this Missing Receipt Declaration
form must be completed by the employee who incurred the expense and is seeking reimbursement from the State of
Vermont. This form is to be used only for an allowable, reimbursable expense (in accordance with Agency of
Administration Bulletin 3.4: Employee Travel & Expense Policy) that was paid for with the employee’s personal funds; it
is not to be used for State purchasing card (P-Card) transactions. The form must be signed by the employee and the
employee’s supervisor, and submitted to the department’s expense coordinator.
EMPLOYEE NAME
EMPLOYEE ID
EXPENSE REPORT #
I am missing a receipt for (description of expense/purchase):
I incurred this expense at:
VENDOR NAME
ON THIS DATE(S)
FOR THIS AMOUNT
The receipt was
:
(check one)
Lost
Never Received
Damaged Beyond Use
Other
o If “Other” provide explanation:
The form of payment I used was
:
(check one)
Cash
Personal Check
Personal Credit / Debit Card
Other
o If “Other” provide explanation:
Employee Certification: I acknowledge that a Missing Receipt Declaration may not be used on a routine basis and
that excessive use may result in revoking the privilege of providing a Declaration in lieu of a receipt. I certify that the
information provided above is accurate, that I have not and will not submit a duplicate claim, and that I have not and
will not seek reimbursement for this expense from any other source. I understand that intentional misrepresentation
of any information on this form may result in disciplinary action, including possible termination of employment.
Employee Signature & Date
Supervisor Printed Name
Supervisor Signature & Date
FM_EXP_MissingReceiptForm_001
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal