Idaho State University
Affidavit of Lost Receipt
Instructions
All information requested o
n this form, needs to be completed before it will be accepted.
Name:
Vendor Name:
City:
Vendor Phone:
Date of Receipt:
Total Cost:
Description of Expense:
Form of Payment:
Cash Credit Ca
rd Check
(Attach Credit Card Slip) Bank:
Draft #
Certification
While on official university busi
ness I incurred the expense described above.
I have lost, misplaced, or
did not receive the receipt documenting payment. I am submitting this in lieu of the missing receipt.
I certify that this
is a proper charge for a cost incurred while on official university business and that I have
not pre
viously requ
ested, nor will I again request, reimbursement for this expense.
Signature Date
Approval
This form may not be used for the following (since a duplicate receipt may be obtained for
these expenses):
1. Lost Air Tickets
2. Car Rental Receipts
3. Lodging Receipts
4. Registration Receipts / Brochures
