PCS - Missing receipt declaration

This form is to be used when all measures to obtain a required missing receipt have been exhausted. It must be completed by the employee submitting the expense.

I am missing a receipt for:

Insert description of item above

I incurred this expense at: Vendor on Date for $ Price

The receipt was (please check one only)

LostNever receivedOther

The form of payment I used (please check one only)

Personal credit cardCashCheckOther

I understand that a Missing Receipt Declaration may not be completed on a routine basis and that overuse may revoke the privilege of providing a declaration in lieu of receipt. I certify that the amount shown is the amount actually paid, and that I have not and will not submit a duplicate claim, and that I have not and will not seek a claim for these expenses from any other source.

Name

First NameLast Name

Email

example@example.com

Signature

Date