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IN61AN RIVER COUNTY <br />CH' 0REN'S SERVICES ADVISORY COMMITTE <br />REIMBURSEMENT REQUEST- FY25-26 <br />Agency Program <br />Adiress Phone <br />Etr ail =ax <br />REQUEST G <br />?ayment <br />Date <br />Payee/Vendor <br />Pay Period <br />Gross Salary <br />`Remove sick, PTO, <br />asd?ar Holidays not <br />recognized by the <br />ou nty. <br />Tax Employer <br />Contribution <br />Retirement Employer <br />Contribution <br />'Employee's cortriC ut is - <br />reflected in gr, -,s - <br />Total <br />Calculated <br />Percentbg( <br />of Total to be <br />Requested <br />Total Requested <br />S <br />11--1011t <br />5 <br />S <br />10-0ki. <br />5 <br />S <br />iC10�i: <br />5 <br />S <br />L?0kt <br />5 <br />5 <br />100ki <br />S <br />S <br />100�i: <br />S <br />S <br />S <br />S <br />S <br />5 <br />S <br />S <br />S <br />S <br />S <br />S <br />S <br />S <br />5 <br />S <br />S <br />5 - <br />S <br />*b.penscs in -_-t i itemizud uiig:nal4n-QUILC und: euuga ui tdi eeled iaiu::k uS piuof ul pdyinuri.. <br />• Salaries must sham a breakdown the hours paid by type (e.g., regular, sick, vacaboa). Please nate the County will, NOT Reimburse for SICK or VACATION <br />tune so those must be deducted from the request Frior to submitting <br />