CSUCI Lost Receipt Form v18-01
IMPORTANT: For lost air tickets, car rental and hotel receipts, a duplicate must be obtained and
submitted along with this completed form.
I, (Claimant’s Printed Name) _______________________________________, have either not
received or misplaced a receipt for items purchased as described below.
This affidavit is submitted in lieu of original receipt and attests:
(Select one)
No original receipt for this expense is available. I have attached a duplicate of the receipt
from the billing agency and proof of payment.
The item was purchased with cash and a replacement receipt cannot be obtained.
The expense was incurred on behalf of University business.
The item and amount of the expense are accurate.
No reimbursement of this expense has been or will be sought or accepted from any other source.
Amount of Receipt: ____________________ Date of Receipt: ___________________
Vendor Name: __________________________________________________________
Description of expense:
_______________________________________________________________________
Claimant’s Signature: ___________________________________ Date:_______________
Approved by:
_______________________ ___________________________ ______________
Print Name Signature Date
Submit this affidavit with the other receipts with the appropriate CSUCI Expense Claim form for
the item.
Lost/Missin
Recei
t Form
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