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MISSING RECEIPT FORM SAMPLE
CERTIFICATION OF UNAVAILABLE DOCUMENTATION
This form should be completed for any LaCarte Purchasing Card transaction that does
NOT have documentation from the merchant. This should be provided to Reviewer as
part of your monthly reconciliation paperwork.
Cardholder Name/Telephone Number:_____________________
Department Name:_______________________________
Merchant Name:_________________________________________
Transaction Date (mm/dd/yyyy):____________________
Transaction Amount (Total Cost) $__________________
Description/Quantity/Cost Per Item/Total Cost per Line
(Add an additional sheet if necessary)
$ $
$ $
$ $
REASON ORIGINAL DOCUMENTATION IS NOT AVAILABLE
CARDHOLDER CERTIFICATION SIGNATURE
I attest the information provided is true and an accurate description of the details of the
purchase. I confirm that every attempt to obtain a duplicate receipt by contacting the
vendor has been made, but have been unable to do so and also hereby certify the
following:
• All items purchased on this P-Card transaction were for (agency name) use. No
personal purchases were made.
• The Cardholder will not seek reimbursement from the (agency name) in any other
manner for this transaction.
• Original documentation is not in Cardholder’s possession for the reasons stated above.
• Cardholder acknowledges that repeated lack of documentation could result in
revocation of their LaCarte Purchasing Card.
Cardholder Name: _________________________ Date: ______________
Signature: ______________________________________________
SUPERVISOR/REVIEWER:
I have accepted the cardholder’s explanation of the loss and inability to obtain a
duplicate receipt; therefore, I am authorizing payment of the receipt or invoice in light
of the circumstances involved.
Supervisor/Reviewer Print & Sign: __________________________________________
Date: _____________________
click to sign
signature
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