11027 CERTIFICATION FOR LOST OR DESTROYED MEAL TICKETS
(Revised & Renumbered 2/65)
A purchaser may be given credit or a refund for the purchase price of meal tickets that are lost or destroyed. The purchaser will sign, under the penalties of perjury, a completed Lost Meal Ticket Certificate similar to the illustration below. A responsible official designated by the person in charge of the institution will approve the Lost Meal Ticket Certificate after checking its reasonableness.
Lost Meal Ticket Certificates will be retained for audit in the chronological order of issuance. Lost Meal Ticket Certificates need not be registered. The file of original copies of Lost Meal Ticket Certificates will be retained by the accounting office.
LOST MEAL TICKET CERTIFICATE
Date_______________
Name of Institution:_________________________________________
Identification of Tickets:
Book No._________ Purchase Price__________ Purchase Date__________
Description of Loss:
Approximate Date Lost or Destroyed____________________________
Number of Tickets Used__________ Number of Tickets Lost or Destroyed_______
Value of Tickets Lost or Destroyed $________________
Briefly describe circumstances of the loss or destruction and efforts made to recover tickets:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
If the above tickets are found subsequent to the date of this certification, the tickets will be turned in for attachment to this certificate.
I hereby certify under the penalties of perjury that the above information is true and correct to the best of my knowledge.
______________________
Signature of Purchaser
APPROVED:
_____________________
Signature
_____________________________
Title of Institution Official
