PROCUREMENT CARD VIOLATION NOTIFICATION
Cardholder Name: ________________________________ Today’s Date:_________________________
School/Department:_______________________________ Reported by:_________________________
Transaction Date: ________________________ Transaction Amount: _________________
Merchant Name:___________________________________
Cardholder-Reported Personal Purchase – 50 points
Personal Purchase Not Reported by Cardholder – 100 points
Transaction over $2500 that was not authorized – 100 points
Split Transaction to circumvent $2500 single transaction limit – 100 points
Purchase by individual not named on card – 100 points
Purchase of Restricted Item: ___________________________________ - 50 points
Itemized Receipt/Line Item Detail is Missing – 10 points and Reimbursement
Missing Receipt (Missing Receipt Affidavit must be completed)– 25 points
Statement not received by the 27
th
of the month – First Offense - 20 points, Second Offense - 30 points, Third
Offense - 40 points, Fourth Offense – Automatic 3 month p-card suspension
Justification for Food Purchase is missing – 10 points
Improper Record Keeping - 20 points
Other:_____________________________________________________________________
ACKNOWLEDGEMENTS & CERTIFICATION SIGNATURES
I hereby acknowledge that the above transaction is in violation of Policies and that I have received a copy of this form.
Cardholder Signature Date
Liaison Signature Date
Approving Officials' Signature Date
According to Procurement records, you have accumulated _________ points within a 12 month period. Therefore, in
accordance with CCSD Procurement Card Policies, the following action is being taken:
Warning
Mandatory Re-Train on _____________________________
Card Suspension
Card Revocation
Procurement Official Signature Date
