LOST RECEIPT VERIFICATION FORM THIS FORM IS TO BE

DATE CERTIFIED MAIL OR HAND DELIVERED CERTIFIED MAIL RECEIPT
(COPY RECEIPT) (CLERK’S DATE STAMP) SUPERIOR COURT OF
(COPY RECEIPT) (CLERK’S DATE STAMP) SUPERIOR COURT OF WASHINGTON

A TOTAL FEE RECEIPT MEETING DATE
A WPS3538 MERICAN DEPOSITARY RECEIPTS (ADR) HOLDINGS OF US
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES AND

Lost Receipt Verification Form

Lost Receipt Verification Form


This form is to be used when a receipt or invoice has been misplaced, destroyed or is not available. Complete all necessary information and submit form with Department Purchase Requisition or Procurement Card Log. Call the Purchasing Office if you have any problems completing the form. You will need to submit one form for each receipt or invoice that you are replacing.



Vendor: _____________________________________ Date of Transaction: __________


Items Purchased Qty Price Total









Total Amount ________________


Method of Payment (check one): Cash ___ Check ___ Credit Card ___

Provide a copy of the check or credit card statement if either of these options is checked.


Reason for no receipt:


Attempted to get reprint of receipt from vendor (check one): Yes ___ No ___

Date(s):

Contact Name(s):

Phone Number:

Reason vendor couldn’t provide reprint:


If no attempt was made to get a reprint please explain why:


I certify that the above expenditure was made on behalf of Pittsburg State University and is for official use of the State of Kansas.


_________________________________________________ ___________

Signature of individual that made purchase Date


_________________________________________________ ___________

Department or Area Head Date

Revised 9/4/02


ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES NOTICE
ACKNOWLEDGMENT OF RECEIPT FOR COMPANYISSUED PROPERTY YOU MAY BE
ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES (ELECTRONIC


Tags: receipt verification, of receipt, verification, receipt