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Miscellaneous Debit/Credit Form

Instructions:

Complete sections I, II, and III in their entirety. This completed form must be included with each Expense Item in the

new Employee Space.

Section I: Cardholder and Transaction Information

Cardholder Name (first then last): Transaction Date:

School/Department Name: Dollar Amount:

Last 4 digits of PCard number: Merchant Name:

Section II: Reason for the use of this form

Fraudulent/unauthorized transaction

Disputed-amount different than vendor’s original quote

Disputed-purchased items never received

Credit for disputed/unauthorized transaction

Adjustment for incorrect amount charged

Additional information

Section III: Approvals

Approvers Print Name Signature Date

1) Cardholder

2) Cardholder's Supervisor

Denver Public Schools | 780 Grant St., Denver, CO 80203 | 720-423-1398 | PCardsupport@dpsk12.org | Purchasing Updated 2.28.2025