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EXHIBIT B <br />INDIAN RIVER COUNTY <br />CHILDREN'S SERVICES ADVISORY COMMITTEE <br />REIMBURSEMENT REQUEST — 2024125 REQUEST # <br />Agency Program <br />Address ^— _— Phone <br />Email Fax <br />Grant Award Amount Prior Disbursements Remaining Award Current Reimbursement <br />Payment Payee/Vendor Total Explanation 1 Expense Type Proof of Payment* <br />Date Expense <br />(e.g., salary, benefits, supplies) (e.g., invoice, paystub) <br />TOTAL <br />'Expenses must include itemized original invoice 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). Please note the County will NOT <br />Reimburse for SICK or VACATION time so those must be deducted from the request prior to submitting <br />I hereby certify that the above costs are true and valid costs, incurred in accordance with the program funding <br />agreement. I further attest that the above costs were not, nor will be, reimbursed through other funding sources. <br />Name and Title Signature Date <br />