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INDIAN RIVER COUNTY <br />CH'LDREN'S SERVICES ADVISORYCOMMRTE <br />REMBURSEMENT REQUEST -FY25.26 <br />Agancy <br />Adiress <br />Errad <br />Program <br />Phone <br />=ax <br />REQUEST O <br />>ayment <br />Date <br />Payee/Vendor <br />Pay Period <br />Gross Salary <br />' 4'emoae sick, PTU. <br />•d;orHolidays nur <br />fecognized by th< <br />County. <br />Tax Employer <br />Contribution <br />Retirement Employer <br />Contribution <br />'Employee'scontributior is <br />reflected in gross <br />Total <br />Calculated <br />Percentage <br />of Total to be <br />Requested <br />Total Requested <br />S <br />100 IL <br />S <br />5 <br />100kt <br />S <br />S <br />10011: <br />S <br />s <br />100: <br />s <br />s <br />1001i <br />s <br />S <br />100ki <br />S <br />5 - <br />5 <br />S <br />S <br />S <br />S <br />S <br />5 <br />S <br />S - <br />S <br />S <br />S <br />5 <br />5 <br />S <br />S <br />S <br />*Expenses must in:tude itemized original invoice and receipt or carceted check as proof of payment_ <br />' Salaries must show a breakdown the hours pard by type (e.g., regular, sick, vacaboe). Please note the County MR NOT Reimburse fo! SiCK or VACATIDN <br />Time so those must be deducted from the request I:rior to submitting <br />