Missing Receipt Declaration

- Reimbursement of expenditure for which no original supporting documents can be provided -

Issuer of the replacement document: (Full name of the person who made the payment)
Project:	sequa-No.:
Amount spent:	Currency:	Date of payment:
Recipient of the payment: (Name, address)
Product/service purchased: (For what purpose was the payment made?)
Reason for the replacement document: (Why can no original document be submitted?)

I hereby confirm that I have actually made the above payment and that I have not received any reimbursement from another party.

Place and date	Signature of issuer