ࡱ> []XYZ` 0bjbj 06o  T   0}\+------$hH VQ]Q    ++:S, oG߯\  $0   tQQ     Missing Receipt Affidavit PCard/SVCard Transactions Warning: Repeated use of this form as substitute documentation could result in a loss of card privileges. Card Number  FORMTEXT       Cardholder Name  FORMTEXT       Date of Purchase  FORMTEXT       Merchant Name  FORMTEXT       Department Name  FORMTEXT       Manager/Department Head Name  FORMTEXT       DESCRIPTION, QUANTITY, COST OF EACH ITEM PURCHASED: Description Quantity Per Item Cost Total Cost  FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT    FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT       REASON ORIGINAL DOCUMENTATION IS NOT AVAILABLE:  FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT       Attach any additional information, correspondence or justification about this transaction. Report the situation to the PCard administrator if the merchant repeatedly does not provide documentation. CARDHOLDER AFFIDAVIT SIGNATURE I hereby certify the following: All items purchased on this card were for University use and no personal purchases were made. I will not seek reimbursement in any other manner for this transaction. Original documentation is not in my possession for the reasons stated above. I acknowledge that repeated lack of documentation could result in revocation of my card. Cardholder Name _____________________________ Signature __________________________________ Date ________ :<FHTVnprF H J L b d f h | ~ °°°{uoe_OeEejh)6CJUjN)hP;hP;CJU hP;CJjhP;CJU hACJ hGCJjhCJUmHnHujh=CJUmHnHu h@CJhh@5 h@5CJ#hh@5CJOJQJ^JaJh5CJOJQJ^JaJ hh@CJ$OJQJ^JaJ$ hhCJ$OJQJ^JaJ$h@jh'U<prF H  L N b d J B@Bdgd1 ^ gd} ^X xgdT gd}$a$$a$gd'0      ( * , @ B D N P R T n t v ظ~xh^jhk H J N 0 d f l n |rl\rrlj ,hTh *CJU hTCJjhTCJUjhCJUmHnHujhTCJUmHnHu h}CJ#h1h@5CJOJQJ^JaJj+hAh=CJUjhkB   468BDFHJ^`bҸҲҸҔҸҔtҸҔdj3hAh=CJUjh3hAh=CJUj2hAh=CJUjh1UmHnHuj|2hAh=CJU h1CJjhw1CJUj2hAh=CJUjhACJU#h1h@5CJOJQJ^JaJ h@CJ hACJ h=CJ'H|'G:*Z,-/00000<gd1<gd1 & F & F<gd}<gd}gd}dgd1blnpz|~D`n%'Gq{9:**ʽyywe#h1h15CJOJQJ^JaJU hCJ hCJ h@5CJ h}5CJ#h}h}5CJOJQJ^JaJ#h}h@5CJOJQJ^JaJ h@CJh}h@CJh hh@ h1CJ hACJjh1UmHnHujhACJUjhw1CJU$BUDGET MANAGER/DEPARTMENT HEAD CERTIFICATION SIGNATURE AND ACTION I hereby acknowledge lack of documentation from the merchant for this transaction and have made the following determination regarding the violation status of this transaction. Mark the appropriate category below and the action shown:  FORMCHECKBOX  This transaction is considered to be a card violation. Action: Notify cardholder and advise that further violations may result in a suspension of card privileges  FORMCHECKBOX  This transaction is not considered to be a violation because through no fault of the cardholder, the receipt could not be obtained from the vendor.  FORMCHECKBOX  This transaction is considered a violation and suspected fraud/misconduct. Action: Report to PCard administrator. 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