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I NIIU1N RIVER COUNTY <br />CHILDREN'S SERVICES ADVISORY COMMITTE <br />REIMBURSEMENT REQUEST- FY25.26 <br />Agency Program <br />Adlress Phone <br />Errail =BX <br />REQUEST I <br />Dayment <br />Date <br />Payee/Vendor <br />Pay Period <br />Gross Salary <br />' �emw e sick. PTO. <br />and;orHolidays not <br />recognized by thee <br />Countv. <br />Tax Employer <br />Contribution <br />Retirement Employer <br />Contribution <br />'Employee's contribution is <br />reflected in gross <br />Total <br />calculated <br />Percentage <br />of Totalto be <br />Requested <br />Total Requested <br />S - <br />1O0% <br />S - <br />S <br />lOvlro <br />$ - <br />S <br />1004b <br />S <br />5 <br />1O0% <br />S <br />S <br />1O0% <br />S <br />S <br />100% <br />S - <br />S <br />S <br />S <br />S <br />- <br />s <br />s <br />S <br />S <br />- <br />5 - <br />S - <br />5 <br />S <br />S <br />S <br />'Expenses must In_tude itemized original Invoice and receipt or carceted check as Amor of paymen,_ S <br />• S=res must snow a breakdown ine hours paid t }' type le -g., regular, sick. vacat any Please rote Me County will NOT RelmDurse for SICK or VACATION <br />tir-te so those must be deducted from the request prior to submitting <br />