Purchasing & Contract Administration	Lost Receipt Itemized Receipt
	Lost / Itemized Receipt Form
	Chancellor's Office Procard Program

I CERTIFY THAT THE FOLLOWING ITEMS WERE ORDERED FROM:
AND RECEIVED ON

Item No:	Qty:	Description:	Unit Price:	Extension:
			$	$
			$	$
			$	$
			$	$
			$	$
			$	$
			SubTotal	$
			Sales Tax (8.25%)	$
			S & H	$
			TOTAL:	$

LOST RECEIPT ONLY:
Reason(s) original, itemized receipt / invoice was not obtained for this order:
I CERTIFY THIS IS NOT A DUPLICATE PAYMENT: Cardholder/ Card Custodian Signature: _____________________	Date: __________
Authorizer Signature: ______________________________	Date: __________