This form is required for any ACARD transaction that does NOT have documentation from the merchant.
Warning: Repeated use of this form as substitute documentation could result in revocation of your ACARD.

Documentation from the merchant is required for EVERY ACARD transaction. Transaction documentation may be:

• Receipt and card transaction slip from the merchant
• Packing slip from the delivery
• Invoice showing credit card payment
• Order form for dues, memberships, subscriptions or similar items

INFORMATION:
ACARD Transaction ID #	_______________________		Cardholder Name	_______________________
Date of Purchase	_______________________		Approving Official Name	_______________________
Merchant Name	_______________________		Department Name	_______________________

DESCRIPTION, QUANTITY, COST OF EACH ITEM PURCHASED:
Description	Quantity	Per Item Cost	Total Cost
___________________________________________	_______	____________	________________
___________________________________________	_______	____________	________________
___________________________________________	_______	____________	________________
Add additional sheet if necessary		Total Cost:	________________

REASON ORIGINAL DOCUMENTATION IS NOT AVAILABLE:

___________________________________________________________________________________

___________________________________________________________________________________

____________________________________________________________________________________

Attach any additional information, correspondence or justification about this transaction. Report information to Buying & Contracting ACARD Program Administration, Campus Box 578, if the merchant repeatedly does not provide documentation.

CARDHOLDER CERTIFICATION SIGNATURE - I hereby certify the following:

• All items purchased on this ACARD transaction were for University use and no personal purchases were made.
• I will not seek reimbursement in any other manner for this transaction.
• Original documentation is not in my possession for the reasons stated above.
• I acknowledge that repeated lack of documentation could result in revocation of my ACARD.

Approving Official Name:	Signature:	Date:
____________________________________	____________________________________	_________

CARDHOLDER INSTRUCTIONS:

• If you do not have documentation from the merchant, contact the merchant to provide the documentation.
• Complete this form whenever you are unable to provide documentation from the merchant for an ACARD transaction.
• Fill out all fields through Cardholder Certification Signature.
• Give the completed and signed form to your Approving Official.

APPROVING OFFICIAL DETERMINATION INSTRUCTIONS:

Determine the Violation Status for the transaction based on the following guidelines:

• ACARD Violation - A transaction where the Cardholder has failed to provide documentation from the merchant but the charge appears to be reasonable for University business is to be considered an ACARD violation.
  Action: A Violation Warning Form is to be completed.
• ACARD Violation Status Waived - The violation status of a transaction may be waived if the Approving Official believes there has been no willful or negligent default on the part of the Cardholder and the charges appear reasonable for University business. Considerations in determining willful or negligent default are:
  • the Cardholder has tried and through no fault of their own, been unable to obtain documentation from the merchant and,
  • the Cardholder is normally responsible and consistent with providing acceptable documentation.
  Action: A copy of this completed form is to be kept with the Cardholder’s ACARD Statement which lists this transaction.
• ACARD Violation and Suspected Fiscal Misconduct - A transaction where the Cardholder has failed to provide documentation from the merchant and the charge does not appear to be reasonable for University business is to be considered an ACARD violation and suspected Fiscal Misconduct.
  Action: The transaction is to be reported to Internal Audit per instructions in the Administrative Policy Statement entitled "Reporting Fiscal Misconduct".