Missing Receipt Statement
Cardholder & Transaction Information
Cardholder Name:______________________________ Current Date:________________
Dept Name:___________________________________ Transaction Date:____________
Index & Acct #:___________________ ____________ Report Month:_______________
Vendor Name:_________________________________ Amount:___________________
Missing Receipt Affidavit
expense. The charge complies with Montana State University's purchasing policy and authorization limits. This form is submitted as
a substitute to the original missing receipt.
Cardholder Signature _________________________________________
(For Acknowledgement of Affidavit)
THIS SECTION TO BE COMPLETED BY
Approved By:__________________________________
(Print)
Signature:____________________________________
Date:_____________
Dept Head
Signature:____________________________________
Date:_____________
One Missing Statement Form per each receipt.
I certify that the transaction amount documented above was incurred on behalf of MSU-Northern as a legitimate business
