PURCHASING CARD UNAUTHORIZED PURCHASE FORM Today’s Date: Cardholder’s Name: 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.
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 ...
Allowed
Microsoft Office Word (.doc, .dot) - application/msword
3300-014 Purchasing Card Unauthorized Purchase Form Update 8-31-18.doc
DELGADO FORMS 
