University of California, San Francisco (UCSF)
Missing Receipt Declaration Form
Department of Finance & Administration
500 Parnassus Avenue
San Francisco, CA 94143
United States
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Missing Receipt Declaration
To Be Completed When Original Receipt Is Unavailable
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Employee Name
Dr. Emily Carter
Department
Clinical Research
Employee ID
UCSF-EMP-45821
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Date of Purchase: 09/22/2026
Vendor Name: MedSupply Co.
Location: San Francisco, CA
Purchase Description: Laboratory consumables and safety gloves
Business Purpose: Required materials for ongoing clinical research study
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1
Nitrile Gloves (Box of 100)
$18.00
1
Lab Safety Goggles
$12.50
1
Disinfectant Wipes Pack
$9.75
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Subtotal$40.25
Tax (8.625%)$1.40
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Payment MethodPersonal Credit Card
Card Last 48821
Reimbursement RequestedYes
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I hereby confirm that the original receipt for the above expense is unavailable.
This expense was incurred for official UCSF business purposes and has not been reimbursed previously.
