Missing Payment Receipt

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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:________________________

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