Lost or Missing Receipt
This form is to be used whenever receipts for NPLB credit card purchases are lost or otherwise missing for any reason. This form must be completed by the individual responsible for the purchase. A new form must be completed for each missing receipt.
This form is being completed by:
*
Must be completed by purchaser.
E-mail:
*
Purchaser's email
Phone #:
Purchaser's phone number
Format: (000) 000-0000.
Vendor Information:
*
Name of vendor
Purchase Price:
*
Total amount on missing receipt
Date of Purchase
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Month-Day-Year
Enter a brief description of the item any why it was purchased:
Credit Card Information
*
Type of card and name or last 4 numbers on card
I certify that I used the NPLB credit card for the information listed above. I am unable to provide the receipt for this charge but verify that it was purchased legitimately and the information I have provided is accurate the best of my knowledge.
*
Submit Form
Should be Empty: