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EXHIBIT B <br />v INDIAN RIVER COUNTY <br />CHILDREN'S SERVICES ADVISORY COMMITTEE <br />' REIMBURSEMENT REQUEST - 2023/24 INQUER # <br />t <br />t <br />6raM Award Amount Prior Disbursamonts Ramabt Current ilaimbursement <br />. - � �" <;±.� 5" st t xa.x x } `� ';` S ., `khyS;ki ♦ ,, +Ac t � � + g%„y a�, `�zx t� uw�y �. , X.:, d., id •. <br />i <br />Payment Total <br />Date Payee/Vendor Expense Explanation Expense Type Proof of Payment* <br />(e.g., salary, benefits, supplies) (e.g., invoice, paystub) <br />) <br />7 77 <br />4 I <br />i <br />i <br />e <br />A <br />�".r, .� � � ✓ � a Via., � �r : �, "�€� - � .+ <br />- - <br />T - <br />*Expenses must include itemized origin voice and receipt or canceled check as proof of payment. <br />*Salaries must show a breakdown the hours paid by type (e.g., regular, sick, vacation). <br />i <br />1 hereby certify that the above costs are true and valid costs, incurred in accordance with the program funding agreement. <br />I further attest that the above costs were not nor will be, reimbursed through other funding sources. <br />s <br />{ <br />Name and Title Signature Date { <br />j <br />( <br />i <br />3 <br />E <br />S <br />176 <br />i <br />