HomeMy WebLinkAboutInv# LexisNexis-Lost - BANK OF AMERICA - 09/13/2021Updated June 2019
Lost/Missing Receipt Form for P-Card
The City of Dania Beach expects your best efforts to obtain original receipts. In the rare event that a receipt
cannot be obtained, or is lost, this form may be used to document your purchase. Excessive use of this
form could result in suspension of purchasing privileges. Supervisor approval is required.
Card Holder Information Vendor Information
Name: ____________________ Last 4 of CC: _______ Name: _____________________________
Department: ___________________ Phone #: ________________ Purchase Date: ______________________
Purchase Information
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
I certify this purchase is a valid City expense
I certify this purchase will not be submitted on any other form for reimbursement
Line Item Detail: Please provide the item description, quantity, and total for each item on the receipt.
Quantity Item description
Individual
amount Total
_____________________________________________________________________
Cardholder’s Signature Date
_____________________________________________________________________
Department Head or Direct Supervisor’s Signature Date
Please provide details as to why the original receipt is not available and how the problem will
be avoided in the future.
Shipping:
Invoice Total:
*If more items were purchased, please
continue on separate page.