Missing Receipt Affidavit Form

This form should be submitted in lieu of the original receipt for an expense you incurred on behalf of
IFO business. This form should only be filled out for expenses that are allowed under IFO policy.

Name

This is your electronic signature

First Name

Last Name

Email Address

Receipt was

Payment for expense was made by

Description of Expense

Vendor Name

Date of Expense

YYYY

Amount

By checking the box below I certify that this is an accurate statement of my expense.