Lost Or Destroyed Receipt Affidavit
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2LOST OR DESTROYED RECEIPT AFFIDAVIT
Please read the Documentation Requirements on the back of this form to determine when this should be used.
Airline: I certify that I have contacted the agency /airline and was unable to obtain a copy of the ticket. Therefore I have attached:
A copy of my AMEX Corporate Card record of charge, my personal credit card statement or a copy of my cancelled check
Hotel: I certify that I have contacted the hotel and was unable to obtain a copy of the hotel folio. However, I am attaching my proof of
payment (credit card statement). Please reimburse me based on the following information:
Dates
Hotel/City
#of Nights
Daily Rate
Total
_________
_________________________
__________
______________
_____________
Car Rental: I certify that I have contacted the car rental agency and was unable to provide me a copy rental agreement. However, I am
attaching my proof of payment (credit card statement). Please reimburse me based on the following information:
Dates
Rental Company
Car Class*
# of Days
Total
_________
__________________________
__________
________
______
*Sub-Compact, Compact, Mid-size, Intermediate, Standard
Meals (list each meal receipt separately)
Date
Restaurant/City
B,L,D
#of People
Food
Alcohol
Total
_______
________________________
_____
__________
$_____
$_______
$_______
_______
________________________
_____
__________
$_____
$_______
$_______
_______
________________________
_____
__________
$_____
$_______
$_______
*B=Breakfast, L=Lunch, D=Dinner (Note: if more than yourself, include the business purpose on Expense Report in Comments. If less than 10 attendees, list each attendee.)
Other
Date
Description
Total
__________
___________________________________
_____________
__________
___________________________________
_____________
I, the undersigned, certify (a) that each expense described above, reported on expense report #_____________
was lost or not obtained, and (b) that these expenses have not nor will again be submitted to Emory University or
any other organization for reimbursement or tax purposes.
Signature of Payee
(required)
_____________________________________ Date ______________
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