If all measures to obtain a required missing receipt have been exhausted, this Missing Receipt Declaration should becompleted by the person who incurred the expense. SBO signature is only required when indicated below. If no SBOsignature is required, this Declaration needs only to be signed by the person who incurred the expense. Because expense reportsand card statements are signed by the supervisor, a supervisor does not need to sign this Declaration.Attach this Declaration to expense report or retain with statement within department for P-Card, Internal Requisition,or Department Card transactions.

I am missing a receipt for:

(Description of item)

The receipt was (check one):

The form of payment I used (check one):

I understand that a Missing Receipt Declaration may not be completed on a routine basis and that overuse mayrevoke the privilege of providing a Declaration in lieu of a receipt. I certify that the amount shown is the amountactually paid, that I have not and will not submit a duplicate claim, and that I have not and will not seek a claim forthese expenses from any other source. I understand that violation of this policy may result in disciplinary action,including termination.

(First Name) (Last Name)

(Signature) (Date)

SBO signature (only when needed, per above) De VP Signature (only needed if SBO is missing receipt)an

University of Southern California, Financial and Business Services, Disbursement Control, Los Angeles, California 90089-1984Tel: (213) 740-9794 Fax: (213) 740-9797 www.usc.edu/dc

Missing Receipt Declaration (Rev. 04-2006)

I incurred this expense at : on for $

Lost Never Received Other

P-Card

Check Cash Other

(Supplier) (Date) (Price)

Division of Financial and Business Services

Disbursement ControlMissing Receipt Declaration

Please describe transaction's business purpose:

TravelPlus Card Personal Credit Card Internal Requisition

Department Debit Card

When to submit Missing Receipt Declaration

Form of Payment If on a Sponsored ProjectAccount

If on anUnrestricted Account

Procurement Card . All amounts (SBO needs to signDeclaration if $15 or more)

All amounts (SBO needs to signDeclaration if $15 or more)

Travel Card All amounts (SBO needs to signDeclaration if $15 or more)

All hotel transactions If single expense of $75 or more

Internal Requisitions /Department Debit Card

All amounts (SBO needs to signDeclaration if $15 or more)

All amounts (SBO needs to signDeclaration if $15 or more)

Personal Funds / Advances /Petty Cash (Replenishment)

All amounts (SBO needs to signDeclaration if $15 or more)

All hotel transactions If single expense of $75 or more

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