Vendor Name:
Address:
Transaction Date: S#
Fund: Org: Acct:
Description of items: (Purchase must be itemized)
QTY
Shipping
Total
Justification for missing receipt:
List attempts for obtaining a duplicate receipt:
Date Name Phone # Resolution
1
2
3
Cardholder Signature: Date:
Supervisor Signature: Date:
PC Coordinator Approval: Date:
I hereby certify that this transaction is for state business, within the guidelines set forth by the
WV Purchase Card Program and was paid for with the Purchase Card.
P CARD MISSING RECEIPT FORM
COST
Revised 9/26/2013
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