1. Department / Contact Information

Name of Employee Requesting Gift Card*
Please include Fund, Department and Object

2. Gift Card Information

List out the denominations and quantities of the gift cards requested ( for example - $10 - 10 nos)


When I purchase/receive custody of these gift cards, I understand that as the Responsible Employee I am responsible to hold, disburse and track them in accordance with Augustana College policies and procedures, including the official Gift Card Policy. Specifically, I understand that these responsibilities include:

1. I will disburse Gift Cards, which can be obtained after approval from The Business Office by submitting the Gift Card Approval Form.

2. I will only disburse the gift cards for the purpose noted on the Gift Card Approval Form and will not disburse the gift cards to anyone related to me.

3. I will track the required information for all gift card recipients on The Gift Card Log

4. I will submit a complete Gift Card Log to the Controller’s Office by the earliest of the following: a) ten (10) business days after disbursement b) sixty days after gift cards were purchased from the Business Office, or c) December 10 of the current calendar year.

5. I will maintain custody of the cards in a secured location with limited access until they are disbursed.

6. I will maintain any tax information obtained on the Gift Card Log in a secured location with limited access.

7. If holding the gift cards for more than one month, I understand that I need to inventory the unused gift cards on a monthly basis to ensure they are all accounted for.

8. I will notify the recipient that if he or she is an employee of the College within the same calendar year or is not an employee but has received more than $600 from the College for services in the calendar year, the value of the gift card will be included in annual tax reporting as taxable income. If the recipient is an employee, the relevant amount of tax will be withheld from his or her paycheck.

9. I am responsible for the gift cards. Any shortages will be reported immediately to the Controller. I understand that I may be held personally liable for any shortfall or misappropriation

3. Policy Acknowledgement

Policy Acknowledgement*
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Controller Authorization

Approval / Denial*
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