ࡱ > [ ] X Y Z ` 0 bjbj 06 o T 0 } \ + - - - - - - $ h H V Q ] Q + + : S , oG߯\ $ 0 t Q Q M i s s i n g R e c e i p t A f f i d a v i t P C a r d / S V C a r d T r a n s a c t i o n s W a r n i n g : R e p e a t e d u s e o f t h i s f o r m a s s u b s t i t u t e d o c u m e n t a t i o n c o u l d r e s u l t i n a l o s s o f c a r d p r i v i l e g e s . C a r d N u m b e r F O R M T E X T C a r d h o l d e r N a m e F O R M T E X T D a t e o f P u r c h a s e F O R M T E X T M e r c h a n t N a m e F O R M T E X T D e p a r t m e n t N a m e F O R M T E X T M a n a g e r / D e p a r t m e n t H e a d N a m e F O R M T E X T D E S C R I P T I O N , Q U A N T I T Y , C O S T O F E A C H I T E M P U R C H A S E D : D e s c r i p t i o n Q u a n t i t y P e r I t e m C o s t T o t a l C o s t F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T R E A S O N O R I G I N A L D O C U M E N T A T I O N I S N O T A V A I L A B L E : F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T A t t a c h a n y a d d i t i o n a l i n f o r m a t i o n , c o r r e s p o n d e n c e o r j u s t i f i c a t i o n a b o u t t h i s t r a n s a c t i o n . R e p o r t t h e s i t u a t i o n t o t h e P C a r d a d m i n i s t r a t o r i f t h e m e r c h a n t r e p e a t e d l y d o e s n o t p r o v i d e d o c u m e n t a tion. CARDHOLDER AFFIDAVIT SIGNATURE I hereby certify the following: All items purchased on this card were for University use and no personal purchases were made. I will not seek reimbursement in any other manner for this transaction. Original documentation is not in my possession for the reasons stated above. I acknowledge that repeated lack of documentation could result in revocation of my card. Cardholder Name _____________________________ Signature __________________________________ Date ________ : < F H T V n p r F H J L b d f h | ~ °°°{uoe_OeEe j h)6 CJ UjN) hP; hP; CJ U hP; CJ j hP; CJ U hA CJ hG CJ j h CJ UmH nH u j h= CJ UmH nH u h@ CJ h h@ 5 h@ 5CJ #h h@ 5CJ OJ QJ ^J aJ h 5CJ OJ QJ ^J aJ h h@ CJ$ OJ QJ ^J aJ$ h h CJ$ OJ QJ ^J aJ$ h@ j h' U < p r F H L N b d J B @ B d gd1 ^ gd} ^X x gdT gd} $a$ $a$gd' 0 ( * , @ B D N P R T n t v ظ~xh^ j hk