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INDIAN RIVER COUNTY <br />CHILDREN'S SERVICES ADVISORY COMMITTE <br />REIMBURSEMENT REQUEST—FY25 26 <br />Agency <br />Adiress <br />Errall <br />P-ograrri <br />P'ionc <br />REQUEST # <br />�syr»ent <br />Date <br />?: « „r <br />Retirement Employer <br />Contribution <br />mploWe's contritwtior <br />reflected in gross <br />Total <br />Calculate <br />Percentage <br />of Total to be <br />Requested <br />Total Requested <br />S <br />100�i <br />S <br />S <br />1001-c <br />S <br />S <br />10T'c <br />S <br />S <br />10011 <br />S <br />1001.IE <br />S <br />10011: <br />S <br />S <br />S - <br />S <br />S <br />S - <br />r <br />5 <br />S <br />S <br />S <br />S <br />S <br />-Expenses must In.lude itemized origrnat Invoice and receipt or carceted check as proof of paymen.. <br />'Satarles must shorn a breakdown he hours paid by" (e -g., regular, sick, vacation). Please note the County will NOT Reimburse for SICK of VACATION <br />time so those must be deducted from the request prior to submitting <br />