DECLARATION OF MISSING EVIDENCE
To: Cal Poly Corporation Business Office Date: ________________
Subject: Missing Original Receipt or Invoice
From: ______________________________ Dept: ________________
This form is in no way intended as a replacement for acceptable receipt documentation,
nor is it evidence of incurred expenses. This form is to simply certify that expense(s)
have been incurred and paid for by me and I am not, and will not be claiming
reimbursement through any other source.
The method of payment was:
□ Credit / Debit Card ** □ Check ** □ Cash
The original receipt or invoice is not obtainable through any means because:
_____________________________________________________________
_____________________________________________________________
**Copy of credit / debit card statement or cancelled check is required.
The following is a breakdown of the purchase(s) for which reimbursement is requested:
Purpose of Expense: Amount: Org / Obj Code: Vendor:
__________________ ____________ _______________ __________________
__________________ ____________ _______________ __________________
Total Reimbursement: ____________
________________________________
Claimant’s Signature
I acknowledge the above expense(s) are being reimbursed without original receipt or
invoice. I am aware excessive instances of lost receipts, or substitutions for the original
receipts, may affect my ability to obtain future reimbursements through the use of this
form.
Revised 10/05/09