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<br /> <br />127 <br />221698v1 <br /> <br />AFFIDAVIT OF LOST OR DESTROYED RECEIPT <br /> <br /> <br /> <br />Name: <br /> <br />Position: <br /> <br />Last four digits of Card Number: <br /> <br />I declare on oath, that the original receipts for the transaction dated _____/______/________ in <br />the amount of $__________ from ____________________________ (vendor name) has been <br />lost or destroyed. The vendor has been-contacted and is not able to provide a duplicate receipt <br />for this purchase. Please accept the detail of the transaction below in lieu of an itemized receipt <br />for this transaction. <br /> <br />Item(s) Purchased Amount <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />I understand that falsification of the itemization of this purchase constitutes an act of fraud. <br /> <br /> <br /> <br />_____________________________________ __________________________ <br />Signature Date <br />