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IN[ IAN RIVER COUNTY <br />CH LDREN'S SERVICES ADVISORY COMMITTE <br />REIMBURSEMENT REQUEST - FY2S 26 <br />Agency <br />Adiress <br />En ail <br />P•ogram <br />P'• o nc <br />REQUEST O <br />payment <br />D rtv <br />PayeeNendor <br />Pay Penod <br />Gross Salary <br />'Remove sick. PTO, <br />3sd or Holidays not <br />recognized by thi <br />ou nty. <br />Tax Employer <br />Contribution <br />Retirement Employer <br />Contribution <br />'Emptoyee'scontributio- c <br />reflected in pros<. <br />Total <br />calcutatel <br />Percentage <br />of Totalto be <br />Requested <br />Total Requ?sted <br />S <br />16(y.n <br />S <br />S <br />1001A: <br />S <br />S <br />100 <br />$ <br />S - <br />10041 <br />S <br />S <br />1oo4v <br />S <br />S <br />1004:: <br />5 <br />5 <br />S <br />S <br />S <br />S <br />S - <br />S <br />S <br />S <br />S <br />S <br />S <br />S <br />S <br />S <br />S <br />S <br />S <br />Expenses must rn_tude itemized original invoice and receipt or carceled check as pruur of payment. <br />'S)lanes must show a breakdown fie hours pard bt type (e.g., regular, sick, vacation). Please note the County will NOT Reimburse fo� SICK or VACATIDN <br />tine so those mus: be deducted from the request Kriof to submitting <br />