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  • Request Receipt

    • UCSF Missing Receipt

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    University of California, San Francisco (UCSF) Missing Receipt Declaration Form Department of Finance & Administration 500 Parnassus Avenue San Francisco, CA 94143 United States

    -------------------------------------------

    Missing Receipt Declaration To Be Completed When Original Receipt Is Unavailable

    -------------------------------------------
    Employee Name
    Dr. Emily Carter
    Department
    Clinical Research
    Employee ID
    UCSF-EMP-45821
    Email
    [email protected]
    Phone
    (415) 555-7821
    -------------------------------------------
    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
    -------------------------------------------
    1
    Nitrile Gloves (Box of 100)
    $18.00
    1
    Lab Safety Goggles
    $12.50
    1
    Disinfectant Wipes Pack
    $9.75
    -------------------------------------------
    Subtotal$40.25
    Tax (8.625%)$1.40
    Total
    $41.65
    -------------------------------------------
    Payment MethodPersonal Credit Card
    Card Last 48821
    Reimbursement RequestedYes
    -------------------------------------------
    1234567890

    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.

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