PCARD Missing Receipt Form
This form is to be used as documentation for missing PCARD receipts ONLY if the merchant cannot produce duplicate
documentation. It is allowed after all other attempts have been exhausted and as a rare circumstance. The form is to be
completed by the Cardholder and must be signed by the Cardholder, Budget Manager/Supervisor and the Procurement
Department. Be aware that repeated use of this form as a substitute for a receipt may result in suspension or cancellation of
your PCARD.
INFORMATION:
Printed Cardholder Name:
Date of Purchase: Receipt Total: Merchant Name:
DESCRIPTION, QUANTITY, COST OF EACH ITEM PURCHASED:
Description of Item(s) Quantity Per Item Cost Tax Paid Total Cost
Add additional sheet if necessary.
REASON ORIGINAL DOCUMENTATION IS NOT AVAILABLE:
WHAT ATTEMPTS HAVE BEEN MADE TO REQUEST A DUPLICATE RECEIPT FROM THE MERCHANT?
(Please include names, dates, phone numbers or emails used in requesting documentation from the merchant.)
CARDHOLDER CERTIFICATION SIGNATURE I HEREBY CERTIFY THE FOLLOWING:
All items purchased on this PCARD transaction were for University use and no personal purchases were made. I will not seek
reimbursement in any other manner for this transaction. I validate that every attempt was made to obtain an itemized receipt
from the merchant. Original documentation is not in my possession for the reasons stated above. I acknowledge that repeated
lack of documentation could result in revocation of my University PCARD.
CARHOLDER SIGNATURE DATE
BUDGET MANAGER/SUPERVISOR REVIEW AND APPROVAL:
By signing below you certify that the cardholder was compliant with the PCARD Policies and Procedures and every attempt was
made to obtain an itemized receipt from the merchant.
BUDGET MANAGER/ SUPERVISOR SIGNATURE DATE
PROCUREMENT DEPARTMENT APPROVAL DATE
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