Free Missing Receipt Affidavit Template (Copy & Paste)

How to use this template

Copy the affidavit text below into Word, Google Docs, or your PDF editor.
Replace every bracketed placeholder with your actual details.
Attach a redacted card or bank statement showing the merchant, date, and amount.
Sign and date the form, and have your manager countersign if required.

Missing Receipt Affidavit

Employee name: [Your full name]
Department / cost center: [Department]
Expense report period: [Month/Year]
Report reference number: [Report ID]

I, [Your full name], hereby state that the following business expense was incurred by me and that the original receipt is unavailable despite a reasonable effort to obtain a duplicate:

Date of expense: [Date]
Merchant / vendor: [Merchant name]
Amount: [$0.00] (including tax / tip / fees)
Payment method: [Card ending in XXXX / Cash / Other]
Business purpose: [Specific reason, e.g., client dinner for Acme Corp Q1 review]
Attendees (if meal/entertainment): [Names or count]

Reason original receipt is unavailable: [e.g., paper receipt lost in transit; merchant could not reissue itemized receipt; email receipt deleted]

I confirm that this expense was incurred for legitimate business purposes, has not been claimed elsewhere, and will not be claimed again. I have attached independent proof of payment (redacted card/bank statement line) and any other supporting documentation available.

Signature: Date: [Date]

Manager / approver signature: Date: [Date]

What to attach

The affidavit is a signed statement, not proof. Most finance teams will ask for at least one of these:

Redacted card or bank statement showing the merchant name, transaction date, and amount. Use the redactor to cover unrelated lines, account numbers, and balances.
Merchant order confirmation email or booking receipt.
Calendar invite, agenda, or trip itinerary proving the business purpose.
Written manager approval, if your policy requires it.

Example of a complete entry

Date of expense: March 4, 2026
Merchant: Delta Air Lines
Amount: $412.60
Business purpose: Q1 customer review trip to San Francisco for Acme Corp account
Reason receipt unavailable: Itemized receipt not reissued by airline; boarding pass and card statement line attached.

Make the proof of payment first

Before you fill out the affidavit, prepare the redacted statement. It is the piece finance actually reviews, and it makes the rest of the form credible.

Redact my statement

When an affidavit may not be enough

Some employers limit how many affidavits you can file per quarter or year. Repeated use, large amounts, or vague business purposes are common reasons for rejection or audit follow-up. If the receipt is truly lost, be specific and attach everything you can.