Missing Receipt Affidavit

Name *
(Business Name)
Date of transaction:
Date of transaction:
I understand that a Missing Receipt Affidavit should be used on rare occasions and may not be used on a routine basis. I further understand that excessive use of a Missing Receipt Affidavit may revoke the privilege of using a company credit card. I certify that the amount shown is the amount I actually paid; that I have not and will not submit a duplicate claim; and that I have not and will not seek a claim for these expenses from any other.
Date *