Lost/Missing Receipt Waiver IMPORTANT: This form is to be used only after all other attempts to obtain the original receipts have been exhausted. This affidavit is submitted in lieu of original receipt (s) and affirms: Please check all boxes. No original receipt for this expense is available. I have attached a duplicate of this receipt from the billing agency/vendor and a form of proof of payment. The expense was incurred on behalf of LBNL and is allowable. The item and amount of the expense is accurate. No reimbursement of this expense has been or will be sought or accepted from any other source. Other (please explain here): ______________________________________________________________________ Trip Document Name and Number (TA):_____________________________________ Division Name: _________________________________________________________ Amount: _______________________________________________________________ Vendor Name: __________________________________________________________ Date of Receipt: _________________________________________________________ Claimant (Traveler’s) Name (printed): _______________________________________ Claimant (Traveler’s) Signature: ____________________________________________ Approver’s Name (printed):________________________________________________ Approver’s Signature: ____________________________________________________ Please forward completed form to Travel Services MS-90J. Be sure and save copy/copies for your records as required by your Division.