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					             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:


Statement Date:

$ Amount:

Tax charged?                      Yes     or No

Supplier Name:

Date of Receipt:

Claimant’s signature:                                                  Date:

Approver’s name:

Approver’s signature:                                                      Date:




PcdLostMissReceiptAffidavit.doc                                               Last revised: 07-24-08

				
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