This form is to be filled out as a one time exception for missing receipts for funds disbursed from the church. Requester acknowledges the following:

1. I am requesting reimbursement for the following expenses for which the itemized receipt(s) are unavailable for my
accounting.
2. This is a one time exception.
3. All receipts must be turned in within one week of purchase.
4. In the event that this matters, happens again, it will result in loss of privileges to obtain funds from the church. The Senior Pastor will be notified of these actions and this will be reported to our Accounting Firm.