Missing Receipt Form
FRD : 05/02/18
FCD : 03/04/2014
Form must be uploaded as the documentation for the transaction.
VENDOR INFORMATION
Individual Signature: Date:
Individual Name: Southeast ID:
All items purchased on this transaction were for University use. No personal purchases were made.
Individual will not seek reimbursement from the University in any other manner for the items purchased on this transaction.
Original documentation is not in the Individual's possession for the reasons stated above.
Individual acknowledges that repeated instances of missing or incomplete transaction documentation may result in revocation of card privileges or
denial of reimbursement.
This form is to be used ONLY if the actual receipt, invoice, packing list, or internet order confirmation
is not available. It will be allowed only in extenuating circumstances. It must be filled out
completely. This form will not be accepted for missing Hotel Folios.
Amount
Supervisor Signature: Date:
By signing this form, I agree that the above transaction was for business purposes. The Individual was reminded that itemized receipts are required
for all transactions.
CERTIFICATION AND SIGNATURE
Vendor Name:
Purchase Date:
Amount of Transaction:
DESCRIPTION OF TRANSACTION
(List Items, Quantities, & Amounts) (Attach additional pages if needed)
In-store On-line by Phone
Transaction was made:
Description Quantity
Explanation for why receipt is missing:
Explain the attempts made to obtain a replacement receipt or documentation from the vendor:
Purpose:
Date:
Provost Signature:
Vice President /
Transaction was paid with:
University Purchasing Card Personal Credit Card Cash Personal Check
(attach copy of statement) (attach copy of cleared check, front & back)
