Missing Receipt Declaration

Boarding Pass(es)

Name of traveller
Flight no.	Date	Departure from	Destination
Flight no.	Date	Departure from	Destination
Flight no.	Date	Departure from	Destination
Flight no.	Date	Departure from	Destination
Flight no.	Date	Departure from	Destination
Flight no.	Date	Departure from	Destination

Hereby, I declare, that I have

lost the boarding pass(es) for the flight(s) listed above and

actually used the flight(s) listed above.

Place and Date	Signature