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Affidavit of Lost or Destroyed Receipt - PCard

  1. Affidavit of Lost of Destroyed Receipt - PCard

  2. I understand that falsification of the itemization of this purchase constitutes an act of fraud:

    I declare on oath that the original receipt(s) in the below itemized listing has been lost or destroyed. The vendor has been contacted and is not able to provide a duplicate receipt for this purchase.

  3. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

  4. Leave This Blank:

  5. This field is not part of the form submission.