Itasca Community College
A member of Minnesota State Colleges and Universities
1851 East Hwy 169
Grand Rapids, MN 55744
AFFIDAVIT OF NO RECEIPT
State of Minnesota
County of
, being first duly sworn, says that
he/she is an employee of the State of Minnesota, Minnesota State Colleges and Universities, and
that on
, 20
, he/she
to
for which a sum of $
was paid.
Paid a registration fee of $
to
Secured lodging at
in
for which a sum of $
was paid.
for which a sum of $
was paid.
And further, that a receipt was not obtained for the above expenditure(s).
And further, that a receipt was obtained but that it was lost.
This
expense was incurred as an employee of the State of Minnesota on official business.
Subscribed and sworn before me this
day of
, 20
Employee Signature
Notary Public
County, Minnesota
My commission expires
Affidavit
11/15/05
Updated
August 2012
Updated March 2014 (fillable .pdf)
Updated August 2016 (adjusted for NHED)
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signature
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