Missing Payment Receipt printable pdf download

Missing Payment Receipt

MISSING PAYMENT RECEIPT

TAPE ITEMIZED RECEIPT BELOW

Restaurant:

________________________________

City/St: _________________________

Date: ____________Time:__________

Sub Total:

$___________

Tax _______%:

$___________

Check Total:

$___________

Tip _______ %

$___________

(cannot exceed 20%)

TOTAL:

$___________

_____ Personally paid for purchase

_____ Credit Card ______ Cash

_____ If total exceeds cap, requesting

cap only $________

______ No alcohol reimbursement

included

Unable to provide payment receipt due to

_____ Restaurant not provide

_____ Lost / Misplaced

_____ Hotel Room Service / In House

_____ Other _______________________

__________________________________

Accept this statement in lieu of payment receipt

____________________________________

(Signature)

____________________________________

(Approved: Agency/Department Representative)

Date:_______________ Day: _____________________________ Meal:________________________

Missing Payment Receipt