LOST/MISSING RECEIPT AFFIDAVIT Name * First Name Last Name Purchase Date * MM DD YYYY Total Cost * Vendor Name * Reason for Expenditure Description * Claimant Signature * Date MM DD YYYY Reason for expenditure description check both boxes * I incurred the expense as described above and have lost, misplaced or was not provided with a receipt I am submitting this affidavit in lieu of the original receipt.,I certify that these are accurate and proper charges for cost incurred while on Hilton Head Presbyterian Church business. GL codebudget line name * OFFICE USE ONLY Approver Signature OFFICE USE ONLY Date MM DD YYYY OFFICE USE ONLY Approver Title Thank you!
