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Summary: UNIVERSITY OF CALIFORNIA SANTA BARBARA UCSB
BERKELEY · DAVIS · IRVINE · LOS ANGELES · MERCED · RIVERSIDE · SAN DIEGO · SAN FRANCISCO SANTA BARBARA · SANTA CRUZ
ACCOUNTING SERVICES & CONTROLS SANTA BARBARA, CA 93106-2040
DECLARATION OF MISSING EVIDENCE THAT A PAYMENT WAS MADE ON BEHALF
OF THE REGENTS OF THE UNIVERSITY OF CALIFORNIA
Submit this form, completed by payee along with the appropriate Payment Request reimbursement
form, when original receipt(s) have been lost or misplaced by the payee. Obtainable substitutes for
lost or unavailable original receipts must accompany this form. This form is in no way intended as a
replacement for acceptable receipt documentation nor is it evidence of incurred expenses.
Please have payee complete one form per missing receipt and attach it/them to the Payment Request
form.
I, _________________________________________, declare that:
(Payee's Name Please Print)
1. Check applicable option:
I disbursed personal monies on behalf of the Regents of the University of California as
needed:
University funds were disbursed on my behalf by the Regents of the University of California
as follows:
Date:___________________ Amount: _____________________
Description:_________________________________________________________________
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