MISSING RECEIPT AFFIDAVIT

Southeastern University | Business Office

(1) PAYEE INFORMATION
Name
Date
Phone
SEU Email
(2) IMPORTANT INFORMATION

The Missing Receipt Affidavit should be used on rare occasions and may not be used on a routine basis. Excessive use of a Missing Receipt Affidavit may revoke the privilege of providing a declaration in lieu of a receipt. Excessive use is defined as using this form more than twice per fiscal year. Please make every effort to contact the vendor/merchant to request a copy of your missing receipt before using this form.

The persons below certify that the amount shown is the amount actually paid; that the payee has not and will not submit a duplicate claim; and that the payee has not and will not seek a claim for these expenses from any other University source.

(3) MISSING RECEIPT INFORMATION
Supplier / Merchant Information
Transaction Date
Business Purpose / Persons Involved
Transaction Amount
Other
(4) RECEIPT AND PAYMENT INFORMATION
The receipt was:
Explanation for missing receipt
Payment Method:
DEPARTMENT NAME
GL ACCOUNT CODE
DEPARTMENT #
(5) APPROVALS SIGNATURES REQUIRED

I certify that the information provided has been reviewed and is accurate, allowable and appropriate. It is within my budgetary authority to approve the expense(s).

Payee
Print Name
Signature
Date
Budget Administrator
Print Name
Signature
Date
Vice President
Print Name
Signature
Date