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					Brock University
Financial and Administrative Services

                           LOST OR UNOBTAINABLE RECEIPT
     To be attached to Travel and Related Expense or Refundable Expense Reports
  This is intended for those RARE occasions when a staff or faculty member is unable
  to obtain an original receipt, or an original receipt has been lost and a duplicate
  receipt cannot be obtained.
  This form MUST be completed for lost original receipts for amounts greater than $25.
  Lost original receipts for amounts totaling less than $25 per report may be noted
  on the expense report and approved by immediate supervisor.

Attached to Travel & Expense or Refundable Expense Report dated:
                                                                                      mm/dd/yy


      Date                   Details of Receipt              Amount                 Account
     mm/dd/yy




CERTIFICATION:
I hereby certify that the expenses listed on this form relate to university business and have
not and will not be reimbursed, in whole or in part, by any other source.

RESEARCH CERTIFICATION:
I hereby certify that any amounts on this form that are for research purposes are for the
purposes for which the grant was awarded and have not and will not be reimbursed in
whole or in part by any other source.
CLAIMANT/RESEARCHER

Print Name:                                                  Title:

Signature:                                                   Date:
                                                                                mm/dd/yy
                                1
IMMEDIATE SUPERVISOR

Print Name:                                                  Title:

Signature:                                                   Date:
                                                                                mm/dd/yy


     Note 1:        Immediate Supervisor signature is NOT required when this form is attached to a
                    Travel & Related Expense or a Refundable Expense Report prior to signature and
                    approval by supervisor.

a6188f47-20f4-482d-9fc4-d3b9fdda0e19.xls version 03/06

				
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