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Program Name: Claim Number: <br />Indian River County <br />Children's Services Advisory Committee Grant <br />Reimbursement Request Form <br />Agency Name: <br />Program Name: <br />Address: <br />Telephone Number: <br />Fax Number: <br />Email Address: <br />Claim Date: <br />Claim Period: From: <br />To: <br />Grant $ Amount <br />Total Amount of Grant. <br />Prior Disbursements <br />Total of all $ received. <br />Award $ Remaining <br />Monies left to draw upon. <br />Current Request <br />$ requested on this Claim. <br />Enclosed are copies of the original bills, with check number and date of payment. <br />A. Salary & Benefits: <br />B. Program Supplies <br />C. Other — <br />D. Other — <br />E. Other — <br />F. Other - <br />TOTAL: <br />I HEREBY CERTIFY that the above costs are true and valid costs, incurred in <br />accordance with the program funding agreement. <br />Signed: <br />Title: <br />S:\Administrative Staf\Share\Grants\Grants 2015.2016\CSAC Indian River County\CSAC Reimbursement Form.doc <br />