UNAUTHORIZED PURCHASE FORM
Purchasing Card Account #:
Supervisor/Budget Head’s Name:
Form Initiated By (Check one):
CARDHOLDER SUPERVISOR/BUDGET HEAD PURCHASING CARD ADMINISTRATOR
Description/Amount/Date of Unauthorized Purchase:
Explanation for Unauthorized Purchase: Provide circumstances causing unauthorized purchase. Add an additional sheet and/or supporting documentation, if necessary.
How Will Purchase Be Reimbursed to the College? Check one:
CARDHOLDER WILL RETURN MERCHANDISE AND PERSONALLY PAY FOR ANY
APPLICABLE RESTOCKING OR RELATED FEES.
CARDHOLDER WILL PAY BY CHECK OR MONEY ORDER TO CONTROLLER’S OFFICE PRIOR SECOND PAYDAY AFTER UNAUTHORIZED PURCHASE WAS NOTED.
CARDHOLDER WILL PAY BY PAYROLL DEDUCTION WITH FORMAL REIMBURSEMENT PLAN SUBMITTED TO CONTROLLER’S OFFICE PRIOR TO THE SECOND PAYDAY AFTER UNAUTHORIZED PURCHASE WAS NOTED.
CARDHOLDER’S PAY CHECK WILL BE DEDUCTE D THE FULL AMOUNT ON THE SECOND PAYDAY AFTER UNAUTHORIZED PURCHASE WAS NOTED. (This also applies when cardholder has made no election to reimburse the College, as per Purchasing Card Policy.)
Signature of Cardholder Date
Signature of Supervisor/Budget Head Date
Original to Purchasing Card Administrator; Copies to Payroll; Cardholder and Supervisor/Budget Head
Form 3300/014 (12/09)
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