HTML Preview Gift Card Receipt Reconciliation page number 1.
RECEIPT/RECONCILIATION FORM
CASH/GIFT CARD
PO #_______ Date ___________ Check #________ Vendor:_______________
CARD #_________________________ PIN #_______ AMOUNT $_________
I have received the Cash/Gift Card listed above, and have read and understand all
procedures pertaining to the use of this Card as printed on the back of this form, and
agree to abide by such guidelines. By accepting this Card, I assume all responsibility
for the Card and will be solely responsible for all purchases made with the Card.
___________ ___________________________
Date Signature of Card Holder
• Original receipts must be attached to this form.
• All purchases are tax exempt – card holder must reimburse for sales tax showing
on sales receipts.
• Any card with a remaining balance must be returned to the Treasurer’s office
along with this form.
Purchase Brief Description Amount Card
Date of Purchase of Purchase Balance
Original Card Value $
___________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Balance of Card-can be forwarded to another Card Receipts/Reconciliation Form__________$______________
I have attached all original receipts pertaining to the purchases made with this card and have included any
reimbursement necessary to the District for sales tax appearing on the receipts or for any receipts which were
lost and are not attached.
Card Holder’s Signature_____________________Date____________________Principal’s Initials__________
Revised 5/09
Procedures on reverse