Free 53879.FH11 - Indiana

P-CARD / TRAVEL CARD PROGRAM MISSING RECEIPT RECORD
State Form 53879 (3-09) Approved by State Board of Accounts, 2009 INDIANA DEPARTMENT OF ADMINISTRATION / PURCHASING

Reset Form

NOTE:

When available, copies of receipts or other information from provider must be attached to support receipt information. RECEIPT INFORMATION

Date paid (month, day, year)

Amount paid

Payee (name of firm, person, etc.)

Location (number and street, city, state, and ZIP code) Description of purchase made

Statement of reason for not having receipt

CERTIFICATION OF CLAIMANT I, ____________________________________________________________________________________, ___________________________________________________________________________,
Name of employee / other claimant Title

certify that the foregoing receipt related to authorized purchase / travel card expenses is not available or obtainable, that the information is true and accurate, and that the amount shown is legally due.
Signature of claimant Date (month, day, year)

AGENCY APPROVAL The above listed expense was incurred following proper policies and procedures and is authorized by me.
Signature of supervisor Date (month, day, year)

DISTRIBUTION:

Original form with agency file.