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INDIAN RIVER COUNTY <br />CH LDREN'S SERVICES ADVISORYCOMMITTE <br />REIMBURSEMENT REQUEST - FY25 26 <br />Agency Program <br />Adiress Phone <br />Errail =ax <br />REQUEST a <br />payment <br />Datu <br />Payee,,Vendor Pay Period <br />Gross Salary <br />kernove sicic, PTt <br />d, or Holidays ne r <br />recognized by the <br />C ou nty. <br />Tax Employer <br />Contribution <br />Retirement Employer <br />Contribution <br />• Employee's contribution <br />reflected in gross <br />Total <br />latculatel <br />Percentagf <br />of Total to t> <br />Requested <br />Total Requested <br />1001C <br />S <br />10011 <br />$ <br />100111: <br />5 <br />S <br />10011t <br />S <br />S - <br />100111 <br />S <br />5 <br />10(r-: <br />S <br />S <br />S <br />S <br />S <br />S <br />S <br />S <br />S <br />5 <br />S <br />S <br />'Expenses must inaude Ftenoted original M VLc; .:..n;l receipt or canceled check as proof of paymen.. <br />S3lar!es must show a breakdown fie hours paid by type Ie -g., regular, sick. vacaboa). Please nate the County wiU NOT Reimburse to- SICK or VACATION <br />tate so those must be deducted from the request Krioi to submitting <br />