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Missing Receipt Affidavit Form

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Missing Receipt Affidavit

Please enter the information below, then select the "Print this Form" button which will print this page which is your Missing Receipt Affidavit. Print the form, complete the signatures, and send it to Accounts Payable, MS #1.

  Detailed Description of Missing Receipt Amount Duplicate Attached
1. Yes No
2. Yes No
3. Yes No
4. Yes No
5. Yes No
I certify that the above mentioned receipt is missing. The original receipt was lost and I was unable to obtain a duplicate receipt from the provider of goods or services for which payment was made.

I certify the expense was incurred in connection with WHOI and is accurately stated on the Travel Expense Voucher/Request for Payment Form. In addition, the reimbursement of the expense has not been or will not be paid from any other source.

Last updated: July 18, 2014

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