FORM D-110

MISSING ORIGINAL RECEIPT CERTIFICATION

It is the employee’s responsibility to retain and submit original receipts for travel expenses greater than $25. If an original receipt is not available, the employee must attempt to obtain a copy from the vendor, or complete this form with appropriate approvals and attach to the Reimbursement Request Form (Form D-100). Missing Receipt Certification Forms that are incomplete or absent the required documentation will be returned.

Please check the appropriate box(es).

Airline Ticket Receipts

__Attached is a copy or fax of the airline ticket receipt.

OR __I certify that I contacted the agency and was not able to obtain a copy of the ticket receipt. Therefore attached is one of the following:

__Boarding pass

__Copy of credit card statement (redacted)

__Other corroborative evidence

Lodging Receipts

__Attached is a copy or fax of the hotel folio

OR__I certify that I contacted the hotel and was not able to obtain a copy of the hotel folio. Please reimburse me for the following:

Date(s) Hotel/City No. of Nights Daily Rate Total

______

______

______

Car Rental Receipts

__Attached is a copy or fax of the car rental agreement

OR__I certify that I contacted the rental car company and was not able to obtain a copy of the rental agreement. Please reimburse me for the following:

Date(s) Rental Company/City Car Class* No. Days Total

______

______

______

*C=Compact, M=Mid-size, F=Full-size

Meals

I certify that these expenses were incurred on behalf of D-H for a legitimate business purpose. Please reimburse me for the following:

Date(s) Restaurant/City Meal Type* No. People Total

______

______

______

*B=Breakfast, L=Lunch, D=Dinner. (Note: indicate business purpose of meal if more than one person involved.)

Other

Attached is a copy or fax of ______. I certify that these expenses were incurred on behalf of D-H for a legitimate business purpose. Please reimburse me for the following:

Date(s) Description Total

______

______

______

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I hereby certify that the receipt for each expense described above was lost, destroyed or not obtained, and that these expenses have not and will not be submitted again to Dartmouth-Hitchcock or any other organization for reimbursement or tax purposes.

Employee Signature:______Date:______

Print Name ______

Supervisor’s Signature:______Date:______

Print Name ______

Director/Manager Signature:______Date:______

Print Name ______

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