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INDIAN RIVER COUNTY <br />CHILDREN'S SERVICES ADVISORYCOMMITTE <br />RE14BURSEKENT BEQUEST - F 25-2& <br />Agency <br />Adiress <br />ErraR <br />REQUEST 4 <br />Program <br />Phone <br />ax. <br />Payment <br />Date <br />Payee vendor <br />Pay Period <br />Gress Salary <br />'Remove sld, PTO, <br />atadior Holidays not <br />recognized by the <br />Cou nty. <br />Tax Emptoyer <br />Contrl'bution <br />Rettnnent Employar <br />Contribution <br />'Emg toWe'scontributlor is <br />reflected in Bross <br />total <br />catrutated <br />Pereentage <br />of Total to be <br />Requested <br />Total Regu4sted <br />S - <br />10(yl% <br />S <br />$ <br />140 <br />S - <br />5 <br />100% <br />$ - <br />$ - <br />100% <br />S <br />$ <br />100 ,* <br />5 <br />S <br />1404c <br />S - <br />5 <br />S - <br />5 - <br />S - <br />S <br />S <br />5 <br />S <br />- <br />$ <br />- <br />S <br />*Expenses must irr_fude ttgmized origknat invoice and receipt or carctLed check as proof of payman... $ <br />*Salaries must shore a breakdown the hours paid by type (e,g.• regular, sick, vacatioa). Please note the County MR NOT Reirnbutse Roi SICK or VACATION <br />time so those mst be deducted from the request Fehr to submitting <br />