Missing Receipt Affidavit
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1
2ROWAN UNIVERSITY
MISSING RECEIPT AFFIDAVIT
Please read the missing receipt Affidavit requirements on the reverse side of this form. Missing Receipt Affidavits lacking the
required information or documentation will be returned to the authorized signer.
Airline Ticket Receipts
Attached is a copy or fax of the airline receipt (last page of the ticket stub).
-OR- I certify that I have contacted the agency and was unable to obtain a copy of the ticket receipt. Therefore I have attached one of
the following:
A copy of the American Express Corporate Card record of charge
\
A copy of the itinerary invoice and form of payment (i.e., credit card statement, cancelled check)
Hotel Folio
Attached is a copy or a fax of the hotel folio.
-OR- I certify that I have contacted the hotel and was unable to obtain a copy of the hotel folio. Please reimburse me based on the
following information:
Dates
Hotel/City
# of Nights
Daily Rate*
Total
__________________
_________________________________ _________
________
________
•
Daily rate excluding taxes and service charges.
Car Rental Agreement
Attached is a copy or fax of the car rental agreement.
-OR- I certify that I have contacted the car rental agency and was unable to obtain a copy of the car rental agreement.
Please reimbursement me based on the following information, and proof of payment:
Dates
Rental Company
Car Class*
# of Days
Total
_______________
___________________________
_______
________
________
* C=Compact, M=Mid-size F=Full-size V=Van
Meals (not included in Per Diem Allowance)
List each meal separately. (Note: If more than I person, please include business purpose on expense reimbursement voucher).
Date
B,L,D*
Restaurant/City
# of People
Total
_______ _____
____________________________________
_________
_________
_______ _____
____________________________________
_________
_________
_______ _____
____________________________________
__________
_________
* B=Breakfast, L=Lunch, D=Dinner
Miscellaneous
Below is a description of the charge and proof of payment.
Date
Description (in detail)
Total
Date
_________ ______________________________________________________________
________
_________ ______________________________________________________________
________
_________ ______________________________________________________________
________
Affidavit
I, the undersigned, certify (a) that each expense described above, reported on my Travel Expense Voucher
dated _____________ _ was lost or not obtained, and (b) that these expenses have not yet nor will again be
submitted to Rowan University or any other organization for reimbursement or tax purposes.
Signature of Payee ____________________________________________________ Date ______________
Required
Authorized Signature
Date ______________
Required
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