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Affidavit of Lost or Destroyed Receipt - PCard

2. Affidavit of Lost of Destroyed Receipt - PCard

4. Employee Name:*

6. Department:*

8. Last 4 Digits of Card Number:*

10. 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.

    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.

12. Item Purchased (details, please)

13. Amount of Item

15. Item Purchased (details, please)

16. Amount of Item

18. Item Purchased (details, please)

19. Amount of Item

21. 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.

    1. I agree.
23. Electronic Signature*

24. Date:*
    Date:

Leave This Blank:


26. 1. Receive an email copy of this form.
27. Email address

    This field is not part of the form submission.

28. Submit

* indicates a required field