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INDIAN RIVER COLNTY <br />CHILDREN'S SERVEES ADVISORYCOMMITTE <br />RE14BURSEMENT REQUEST- FY25 26 <br />Agency Program <br />Ad3ress Phone <br />Ernell =ax <br />REQUEST � <br />aayment <br />Date <br />Payee Vendcr <br />Pay Period <br />Gross Salary <br />'Kemave sicK, PTU. <br />• d; c r H DI iid ays ne r <br />fecognized by tN <br />C Du ntY. <br />Tax Employer <br />Contribution <br />Retirement Employer <br />Contribution <br />• Employyee's`c�orntribution is <br />reflected in gross <br />Total <br />Calculated <br />Percentage <br />of Totaltob8 <br />Requested <br />TootatRequnsted <br />5 <br />1QCllc <br />S <br />S <br />14Cl� <br />5 <br />S <br />1GC1i: <br />5 <br />S <br />10cli: <br />S <br />5 <br />10G •i <br />5 <br />S <br />1r Cl : <br />5 <br />S <br />5 <br />S <br />5 <br />5 <br />5 <br />5 <br />S <br />S <br />S <br />S <br />5 <br />5 <br />C <br />c <br />S <br />S <br />*Expenses must in.lude itemized original Invoice and receipt or carceled check as proof of payment. <br />• Salanies must shah a breakdown the hours paid try type (e -g.. regular, sick. vacation). 'Please note the County vii R NOT Ref mburse for SJCK w VACATIO N <br />time so those must be deducted from the request mor to submitting <br />