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<br />13 <br />216348v2 <br /> <br /> <br /> <br />This is to certify that on________________________ 20______________________________ <br /> <br />I paid the sum of $______________for____________________________________________ <br /> <br />___________________________________________________________________________ <br /> <br />Vendor’s Name_______________________________________________________________ <br /> <br />Vendor’s Address_____________________________________________________________ <br /> <br />____________________________________________________________________________ <br /> <br />ITEMS COST <br /> <br />__________________________________ ______________________ <br /> <br />__________________________________ ______________________ <br /> <br />__________________________________ ______________________ <br /> <br />__________________________________ ______________________ <br /> <br />__________________________________ ______________________ <br /> <br />__________________________________ ______________________ <br /> <br />TOTAL COST ________________________ <br /> <br />I further certify that the itemized receipt for this payment has been lost or was not received from the <br />vendor and that this statement is given in lieu of that itemized receipt to document the expenditure. <br /> <br />I certify that the expenditure incurred was solely for the benefit of the City of North St. Paul. I also <br />certify that information identified above is valid and accurate. <br /> <br />SIGNED________________________ <br /> <br />PRINTED NAME________________________ <br /> <br />APPROVED FOR EXPENDITURE: _______________________________ <br /> <br />DEPARTMENT HEAD _______________________________ <br />Attachment A.4 <br />City of North St. Paul <br />Credit Card Missing Receipt <br />Affidavit