P-Card Receipt Exception Form

Instructions: Use this form when a receipt was not provided after a transaction or when a receipt was lost. Please complete and return the form to Purchasing. 

1. Cardholder Name:  ____________________________________________________________________
2. Work Number:   ________________________________________________________________________
3. Supervisor: ____________________________________________________________________________
4. Department:  __________________________________________________________________________
5. Transaction ID:  ________________________________________________________________________
6. Transaction Date:  _____________________________________________________________________
7. Posting Date:  _________________________________________________________________________
8. Amount:  ______________________________________________________________________________
9. Merchant Name:  ______________________________________________________________________
10. List Items Purchased:  __________________________________________________________________
11. Indicate reason receipt was unavailable:   ______________________________________________

I certify that the referenced transaction is a valid purchase. 

Signature: _______________________________________________ Date:  _______________________