LOST/MISSING RECEIPT AFFIDAVIT

Claimant Name *

First Name

Last Name

Purchase 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.

Date

MM

DD

YYYY

(FOR OFFICE USE ONLY) Date

MM

DD

YYYY