BELOIT COLLEGE
MISSING RECEIPT
AFFIDAVIT
Airline Ticket
Receipts
[ ] I certify that I contacted the agency and was unable to obtain a copy of the ticket receipt. I have attached a copy of the
itinerary.
Hotel
Folio
[ ] I certify that I contacted the hotel and was unable to obtain a copy of the hotel folio. Please reimburse me based on the
following information.
Dates Hotel/City # of Nights Daily Rate Total
$
$
Car Rental
Agreement
[ ] I certify that I contacted the rental car agency and was unable to obtain a copy of the car rental agreement. Please reimburse me
based on the following information:
Dates Rental Company Car Class* # of Days Total
* C=Compact, M=Mid-size, F=Full-size
$
Meals (list each meal
separately)
Date B,L,D* Restaurant/City # of People Total
$
$
$
* B=Breakfast, L=Lunch, D=Dinner
$
Additional instructions: On the Employee Expense Reimbursement Form, please include the names of the individuals at the meal,
their relationship to the College, and the business purpose.
Miscellaneous
Date Description (in detail) Total
$
$
$
$
I, the undersigned, certify (a) that the itemized receipt for each expense described above was lost or not obtained and (b) that these
expenses have not yet been and will not again be submitted to Beloit College or any other organization for reimbursement.
Please attach copies of credit card statements, cancelled checks, and any other support
available.
Signature
of
Employee
Date
Signature
of
Supervisor
Date
NOTES
This form may not be used for Federal grants—itemized receipts are required.
To be reimbursed tax-free, itemized receipts are required for all lodging and for other travel and entertainment costs of $75 or
more (other than mileage reimbursed at standard rates).
Vendors can often provide duplicate itemized receipts based on information included on credit card slips.
Please try to get a duplicate receipt before completing this form.
