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
, being first duly sworn, says that
he/she is an employee of the State of Minnesota, Minnesota State Colleges and Universities, and
Purchased a ticket for transportation from
Paid a registration fee of $
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.
expense was incurred as an employee of the State of Minnesota on official business.
Subscribed and sworn before me this
Updated March 2014 (fillable .pdf)
Updated August 2016 (adjusted for NHED)
click to sign
click to edit