Fillable Purc Procard Lost Receipt Form Secure (California State University, Chico)

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Purc Procard Lost Receipt Form Secure (California State University, Chico)

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CALIFORNIA STATE UNIVERSITY CHICO
FINANCIAL SERVICES
PROCUREMENT AND
CONTRACT SERVICES
KENDALL HALL ROOM 206
CHICO, CA 95929-0244
530-898-5134
www.csuchico.edu/purc
Lost Receipt
Notication Form
SIGNATURE PRINT NAME DATE
SIGNATURE PRINT NAME DATE
AUTHORIZATION
Please accept this memo as evidence of purchase in lieu of the original itemized receipt. I am aware that excessive instances of lost receipts may result in
my procurement credit card privileges being suspended or revoked.
Cardholder:
Approving Ofcial:
P&CS: Lost Receipt Notication Form Updated July 2014
CARDHOLDER AND VENDOR INFORMATION
Date: Date of Purchase:
Cardholder’s Name: Department:
Vendor’
s Name:
Vendor’s Address:
Reason(s) itemized receipt was not obtained:
DESCRIPTION OF PUR
CHASE
Quantity Detailed Description of Purchase Unit Price Extended Price
Quantity Detailed Description of Purchase Unit Price Extended Price
Quantity Detailed Description of Purchase Unit Price Extended Price
Quantity
Detailed Description of Purchase Unit Price Extended Price
Quantity
Detailed Description of Purchase Unit Price Extended Price
Quantity
Detailed Description of Purchase Unit Price Extended Price
Quantity
Detailed Description of Purchase Unit Price Extended Price
Quantity
Detailed Description of Purchase
Unit Price Extended Price
Sub Total
Tax
Shipping
TOTAL
Purpose: If a procurement card receipt is lost, a duplicate copy of the receipt shall be requested from the
vendor. If the vendor cannot provide a duplicate copy, complete this form as verication of the purchase.
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Purc Procard Lost Receipt Form Secure (California State University, Chico)

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Completed 19 July 2020

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