Lock Haven University of Pennsylvania
	Purchasing Card Missing Receipt Form
	I,		, have either not received or have misplaced a Purchasing Card receipt, i.e.,
	merchant sales slip.
		This form is submitted in lieu of the original receipt.
		Cardholder Name:
		Card Number:
		Department:
		Date of Transaction:
		Vendor Name:
	#	Item Purchased and Purpose		Quantity	Unit Price	Amount
	1
	2
	3
	4
	5
	6
	7
	8
	9
	10
	11
	12
					Total	$                                                            -
	I certify that the amounts shown above were expended for Lock Haven University business purposes.
		Cardholder Signature:			Date:
		Dean/Chair/Director Signature:			Date:
	One form must be filled out for EACH missing receipt.  Submit this form with your other receipts and
	your transaction log, within five business days of receipt of your monthly statement.
Revised: 7/26/06