Certified Statement for Receipts
This form must be attached to the Invoice Control Document (ICD), Business Procurement
Card (BPC) or Travel Reimbursement (TR) before submitting to Financial Operations.
Required original itemized receipt: (please check applicable statement below)
was obtained from the vendor but the receipt is illegible
is missing because an itemized original is not available from the vendor
is not attached because the receipt was lost and all measures to obtain a duplicate receipt
have been exhausted
Vendor’s Name:
Date of Purchase: Total amount of receipt:
Description and cost o
f each item purchased:
Claimant Certifica
tion:
I certify that the itemized receipt for this payment/reimbursement has been lost or was not received from
the vendor and that this statement is given in lieu of the itemized receipt to obtain payment/
reimbursement for this expenditure. The expense was incurred on behalf of Wichita State University.
The description and cost of the expenses are accurate. I further certify that the above claim is correct,
due, and unpaid, and that no payment/reimbursement of this expense has been or will be sought or
accepted from another source. Alcohol was not purchased or included in this expenditure.
Date:
Claimant myWSU ID:
Claimant’s Signature:
Claimant Printed Name:
Phone: Email:
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