Fill - Free fillable MissingReceiptDocumentation - MISSING RECEIPT DOCUMENTATION

MISSING RECEIPT DOCUMENTATION

Check One:

Procurement Card Reimbursement Travel

Vendor Name: ________________________________________________________________________________________

Amount: _____________________________________________________________________________________________

Date Purchased: _______________________________________________________________________________________

Items Purchased:

Purpose of Purchase:

Please explain the circumstances resulting in the missing receipt:

Please explain the action taken to obtain a duplicate receipt from the vendor:

Please attach official documentation which certifies the transaction occurred (for example: credit card/debit card statement,

cancelled check, etc).

I certify and attest that the above statements are true and I have incurred the described expenses. I further certify that these

expenses were for official University purposes. I also have read and understand the University’s policy requiring original

receipts for reimbursement requests. This policy can be found at http://www.westga.edu/purchasing/index_2669.php

_________________________ __________________________________________ _________________________

Print Name Signature of Purchaser Date

_________________________ __________________________________________ _________________________

Print Name Supervisor/Department Head Signature Date

__________________________________________ ____________________________

Business & Finance Approval Date

Office of the Controller

Carrollton, Georgia 30118-4220

Division of Business and Finance

EXPLANATION OF THE PUROSE OF THE FORM

The use of this form does not replace the need for the individual to safeguard the original receipts or documentation required

for reimbursement of expense. The University of West Georgia recognizes that receipts can be lost or destroyed or in rare

cases, a physical receipt may not be possible. This form is used, in these circumstances, to document the specific information

regarding the expenditure and the disposition of the missing receipt.

This form should be completed by the individual with the information/knowledge to answer the questions; signed by the

individual and their department head. Final authority to utilize this form for payment/reimbursement purposes rests with the

appropriate department head in Business and Finance.

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MissingReceiptDocumentation - MISSING RECEIPT DOCUMENTATION_rev3

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