Appendix F - Sample declaration | National Joint Council

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December 1, 2026

Note: This document is intended only as a sample to illustrate the information that should be contained in a declaration when original receipts or copies are lost, accidentally destroyed or unobtainable. The amounts reported below must include all taxes paid.

SAMPLE LOST OR DESTROYED RECEIPT DECLARATION

Declaration by Claimant – To be used in lieu of unavailable receipt
	I,		hereby
	declare that I have paid for the following goods or services incurred by me on travel for government business and that the invoice was:
		Lost
		Destroyed
		Inadvertently not obtained
		Other (specify):

Invoice detail:

Date	Person / Business	Amount
		$

	TOTAL (including any taxes paid)	$
Description of Goods or Services provided:

Signature of Claimant