When a receipt is lost or otherwise unavailable and all measures to obtain a copy have been
exhausted, the Missing Receipt Affidavit should be completed. It should be signed by the
employee and the employee’s supervisor and submitted with the employee’s reimbursement
request, unless the transaction was placed on an employee’s Procurement card. In the case of a
Procurement card transaction, the Missing Receipt Affidavit should be submitted with the JP
Morgan statement in lieu of a receipt.
NOTE: A Missing Receipt Affidavit is not required for tips.
I am missing a receipt for:
I incurred this expense at: on: for:
Business Name Date Expense Amount
The receipt was (check applicable):
Never Received
The form of payment I used (check applicable):
Procurement card
Personal Credit Card
o Cash
Business Purpose of Transaction:
Person(s) involved (if expense is related to travel or entertainment):
I understand that a Missing Receipt Affidavit should be used on rare occasions and may not be used on a routine
basis. I further understand that excessive use of a Missing Receipt Affidavit may revoke the privilege of providing a
declaration in lieu of a receipt.
I certify that the amount shown is the amount I actually paid; that I have not and will not submit a duplicate claim;
and that I have not and will not seek a claim, for these expenses from any other source.
Employee Signature Supervisor Signature
Employee Name (Printed) Supervisor Name (Printed)
Date Date