Microsoft Word - Replacement Receipt Form - 12-15-10
Attachment VPurchasing Card Replacement Receipt FormVendor: Vendor Address: Vendor Phone: Date of Purchase: Total Purchase Amount: Description of PurchasePurpose of PurchaseQuantityPrice/Each(Please use additional sheet if necessary)Original receipt was (check one):LostNot Obtainable*If Not Obtainable, explain why: 91440014224000I, , the undersigned do certify that (Type or Clearly Print Name)the above purchase was made for official state business.91440014287500548640014287500Cardholder SignatureDate91440014287500548640014287500Division Manager SignatureDate89535017653000* If the original receipt cannot be obtained before the charge has appeared in WORKS thisform must be completed and the charge must be approved. Do not hold a charge in WORKS while you are waiting on an original receipt. Please continue to make every effort to obtain an original receipt from the vendor, in addition to completing this form. If original receipt is obtained after this form has been completed and forwarded to accounting, place receipt in new Purchasing Card envelope and reference which period the form was originally sent to accounting.Note: This form is a last resort. It is not acceptable to use this form as a regular practice. Overuse of this form will result in your card being suspended or cancelled. ................
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