DEPARTMENT OF FINANCE AND ADMINISTRATION FINANCIAL CONTROL DIVISION AFFIDAVIT FOR LOST RECEIPTS Travel and Per Diem I, _________________________certify that actual receipts for expenses in the amount of (print name and business unit) $ _____.__ incurred while in the conduct of business for the State of New Mexico, were lost. Travel Dates Lodging Expenses Meal Expenses Other Expenses (date & times of (name of vendor, actual (name of vendor, actual (name of vendor, actual expenses incurred) dollar amounts incurred dollar amounts incurred dollar amounts incurred & description) & description) & description) _____________________ ________________ Employee Signature Date ____________________________ _____________ Agency Head Signature Date
DEPARTMENT OF FINANCE AND ADMINISTRATION FINANCIAL CONTROL DIVISION AFFIDAVIT FOR LOST RECEIPTS Travel and Per Diem I, _________________________certify that actual receipts for expenses in the amount of (print name and business unit) $ _____.__ incurred while in the conduct of business for the State of New Mexico, were lost. Travel Dates (date & times of expenses incurred) Lodging Expenses (name of vendor, actual dollar amounts incurred & description) Meal Expenses (name of vendor, actual dollar amounts incurred & description) Other Expenses (name of vendor, actual dollar amounts incurred & description) _____________________ ________________ Employee Signature Date ____________________________ _____________ Agency Head Signature Date
AFFIDAVIT_of_lost_receipts_FY_17.docx