LOST/ MISSING RECEIPT FORM
Arkansas Department of Finance & Administration – Office of State Procurement
Cardholders should attempt to obtain copies of missing receipts from the vendors.
Current Date Cardholder Last Name Cardholder First Name Middle Initial
Last 6 digits of Credit Card Card Type
Purchase Card Travel Card CTS Account
Agency Name Agency Business Area*
Complete One Form Per Lost/Missing Receipt or Invoice
Vendor/Merchant Name Vendor Merchant City/State Date of Purchase
Justification for Purchase:
Detailed Description of Items Purchased (attach additional sheet if necessary) Item Amount
Total Purchase Amount
Employee Understanding/Signature
*Required Signatures
I certify that I made the purchase shown above for official State business only but I do not have a receipt because
(check all that apply):
I had a receipt but lost it
I requested receipt/invoice, but vendor has not provided it
Vendor did not provide a receipt
Other______________________
This document will be used in lieu of receipt/invoice. I understand that repeated loss of receipts instead of obtaining
original receipts may result in suspension, termination or other disciplinary action with the use of my account.
*Cardholder Signature & Date:
________________________________________________
*Liaison
Name:__________________________________________
(Please Print)
*Liaison Signature & Date:
_________________________________________________
*Approving Manager Name:___________________________________
(Please Print)
*Approving Manager Signature:________________________________
Date: ________________________________
Revised 02/2013
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