Employee’s Name__________________________________

(Last Name - First Name - Middle Initial)

EMPLOYEE REIMBURSEMENT MISSING ITEMIZED RECEIPT/

DOCUMENTATION AFFIDAVIT

University of Massachusetts Amherst

TO BE COMPLETED BY EMPLOYEE BEING REIMBURSED

I certify that the receipt/documentation described below was lost and that I have been unable to obtain a duplicate from the vendor to which payment was made. It has not nor will it be submitted for reimbursement to the University of Massachusetts or any other organization.

Please complete and sign this form, and mail attach to the disbursement voucher for review.

Description

Total Price

Employee’s Signature incurring the expense:

Date: