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AFFIDAVIT OF LOST OR DESTROYED RECEIPT <br />Name of Cardholder and/or Purchaser: <br />Position: <br />Last four digits of Card Number: <br />I declare on oath, that the original receipt for the transaction in the amount of <br />$ from (vendor name) has been <br />(check one): <br />❑ Lost <br />❑ Destroyed <br />❑ Not obtained (Explanation: <br />The vendor has been -contacted and is not able to provide a duplicate receipt for this purchase. <br />Please accept the detail of the transaction below in lieu of an itemized receipt for this <br />transaction. <br />Date Purchased Items) Purchased Amount <br />I understand that falsification of the itemization of this purchase constitutes an act of fraud. <br />Signature of Cardholder <br />Date <br />Page 134 of 151 <br />230 <br />