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Lost or Missing Receipt Affidavit
I certify the receipts supporting Jefferson travel expenses described below
totaling
have been lost or are otherwise
unobtainable.
Expenses incurred were:
Vendor/Description
Date
Amount
Sub-total
I verify that the undocumented expenses are legitimate Jefferson expenses.
I have attempted to get the following (mark all that apply):
Duplicate Receipt
Other supporting purchase documentation from vendor
Employee Signature
Campus Telephone
Date
Print Name of Employee
Approver/Supervisor Signature
Print Name of Approver/Supervisor
(Note: Attach Affidavit to Report of Travel Expenses)
Date