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Eugene Central Services Procurement Card Program <br /> Finance MISSING RECEIPT FORM <br /> If you cannot provide an original or duplicate receipt for a procurement card transaction: <br /> • fill out the information requested below <br /> • sign the form <br /> • obtain your Approver's signature <br /> • upload the form tothe transaction line in PeopleSoft. <br /> Cardholder Name: A ►may Meeker' <br /> Department/Division: r 0 S <br /> Reason Receipt is Missing: <br /> -1 Lost 0 Other(describe): <br /> 7 Receipt not provided by Supplier <br /> Supplier Name: A-ikska par Tr-I(13k - <br /> Supplier Location: City EIA6trt orea+- State OR <br /> Itemized Description <br /> rofTransaction: (2) 5 made._ n 6r 1 sck2S4 Ir f�$aAfer 5 <br /> Business Purpose: food 4r S 1/2 kr. Trip <br /> Transaction Amount$: I 9 <br /> 0 0 <br /> Transaction Date (MM/DD/YY): 9 /19 <br /> Efforts made to obtain a copy of the receipt from the Supplier(describe): <br /> Nona a.) a-A(ahle ew clave. . acci;QI . c Lcs-ed P-(avd <br /> (Attn if should ftitiuq A Pato tkirfh ww Per (7r'Prn .I -( <br /> /- fa v`-'` . <br /> *Category Codega4g� *Work Unit: q� � *Fund: Off *Program: (trIpbrr4t <br /> SA <br /> *Location: Project: Activity: Resource Type: ,d4,n <br /> I certify that this transaction was actual and reasonable and incurred for City business. No portion of this p' ato v1/4 <br /> claim was provided free of charge, previously reimbursed from any other source,or will be paid from any <br /> other resource in the future. Should any portion of this transaction be found non-compliant with City of <br /> Eugene policy, I will reimburse the City within <br /> thirty(30) days of being so notified. <br /> Cardholder Signature: ntWLe <br /> C Date: /0(I SIS q <br /> 17 Approver Signature: r �. ,� Date: (64/ <br /> ' Version:August 2019 <br />