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INDIAN RIVER COUNTY <br />CHILDREN'S SERVICES ADVISORYCOMMITTE <br />REIMBURSEMENT REQUEST - FY25-26 <br />Agency <br />Adiress <br />Errait <br />Program <br />Phone <br />=ax <br />REQUEST I <br />payment <br />Date <br />PayeeJVendor <br />tea,, Period <br />Gross Salary <br />'Remove sick, r' 1 j <br />3nd.orHolidays nst <br />recognized by the <br />Countv. <br />Tax Employer <br />Contribution <br />Retirement Employer <br />Contribution <br />: inployee'scontributia- <br />reflected in gros< <br />Total <br />Calculated <br />Percentage <br />of Totaltobe <br />Requested <br />Total Requested <br />1001•t <br />100ki <br />5 <br />S <br />l0ae <br />5 <br />S <br />10011t <br />S <br />S <br />loan <br />5 <br />S <br />100`•t <br />S <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 />S <br />S <br />S <br />*Expenses must in.lude itemized original invoice and receipt or carceled check as proof of paymen.. <br />'SaLar.es must show a breakdown 1ne hours paid by'type (e.g., regular, sick, vacation). Please note the Courcy wia NOT Reimburse fu SICK or VACATION <br />time so those must be deducted from the request Krior to submitting <br />