UNIVERSITY OF CALIFORNIA SANTA CRUZ
Purchasing Card Program (Pro-card)
Receipt Affidavit: Lost/Missing Details
Acceptable documentation includes itemized receipts or packing slips, magazine
subscription form, Internet purchase screen shot or email acknowledgement of an Internet
order. Receipts/documentation must contain details. Include the supplier name, item
description, item cost, total transaction cost, date of purchase, shipping and handling
costs (if applicable) and sales tax charged.
Please complete this form for missing detail, sign and obtain approver’s signature. Attach
to statement along with other proof of purchase (i.e. packing slip, email confirmation,
Internet screen shot) when you submit monthly statement to FAST.
I, , have either not received or have misplaced
a receipt totaling $ .
This affidavit is submitted in lieu of the original receipt and attests:
No original receipt for this expense is available. I have attached a duplicate of this
receipt from the billing agency and proof of payment.
The expense was incurred on behalf of University business.
The item and amount of the expense are accurate.
No reimbursement of this expense has been or will be sought or accepted from
any other source.
Description of expense:
Tax charged? Yes or No
Date of Receipt:
Claimant’s signature: Date:
Approver’s signature: Date:
PcdLostMissReceiptAffidavit.doc Last revised: 07-24-08