UNIVERSITY OF THE VIRGIN ISLANDS 
PURCHASING DEPARTMENT 
PROCUREMENT CARD LOST RECEIPT/INVOICE AFFIDAVIT 
 
Please retain this form with the relevant JP Morgan Chase Procurement Card Statement in case of an audit. 
Name (please print):   
 
 
 
 
 
 
 
 
 
I certify that I made the purchase shown below for the University of the Virgin Islands but do not have a 
receipt because (check all that apply): 
 
Vendor did not provide a detailed receipt. 
 
I have requested an invoice, but the vendor has not provided it. 
 
I had a receipt but cannot locate it. 
 
I have a receipt, but it is not readable (ie, not in English and/or not legible).  This document is 
provided in order to describe the items purchased. 
 
Order was placed via telephone, fax, or Internet, and vendor has not supplied an invoice. 
 
Vendor Name1 
 
City 
 
Date of Purchase 
 
Detailed Description of Purchase (attach an additional sheet if necessary) 
Item Amount 
 
 
 
 
 
 
 
 
 
 
Total Purchase Amount 
 
 
This document is in lieu of an invoice or receipt for this transaction.  I certify that all items listed above 
(and on the attached, if applicable) were purchased and received for University of the Virgin Islands 
business. 
Employee Signature:    
 
 
 
 
Date:    
 
 
Supervisor Signature:    
 
 
 
 
Date:    
 
 
Supervisor Name (print):   
 
 
 
 
 
 
 
 
 
 
 
1 All information is required and must be typed or printed in ink.  (Use one affidavit per receipt.) 
Approved March 2015