MISSING RECEIPT DOCUMENTATION FORM
Complete this form when an original purchase receipt is unavailable.
Individuals Name:
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Please Select
Date of Purchase IF YOU PUT THE WRONG DATE OF PURCHASE YOU WILL HAVE TO REDO THE ENTIRE FORM:
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Store / Merchant:
*
Amount of Purchase IF YOU PUT THE WRONG AMOUNT YOU WILL HAVE TO REDO THE ENTIRE FORM :
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DSP/Office Staff:
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First Name
Last Name
Staff - Only use if need room to add staff present for the purchase name:
First Name
Last Name
Reason Receipt Is Unavailable PLEASE CHOOSE THE RIGHT REASON, PLEASE READ THE OPTIONS:
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Merchant did not provide a receipt
Merchant receipt printer/paper unavailable
Kiosk/machine did not issue a receipt
Internet or technical issue prevented receipt retrieval
Behavioral or safety incident prevented receipt retrieval
Staff was unable to safely retrieve receipt at time of purchase
Individual retained receipt
Individual declined to provide receipt
Individual misplaced or lost receipt
Receipt was damaged and is unreadable
Receipt was dropped or otherwise lost after purchase
Receipt was accidentally discarded
Caregiver/staff misplaced or lost receipt
Other - explain below
YOU DO NOT NEED TO COMPLETE THIS IF YOU SELECTED AN OPTION ABOVE. THIS IS ONLY FOR PEOPLE WHO SELECTED OTHER - EXPLAIN BELOW Other Explain Below :
Signature:
*
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