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INHAN RIVER COUNTY <br />CH LDREN"S SERVICES ADVISORY COMMITTE <br />REMBURSEMENT REQUEST - FY25 26 <br />Agency Program <br />Adiress Phone <br />Err aR =ax <br />REQUEST 4 <br />payment <br />(late <br />Payee'Venjor <br />Pav Period <br />Gross Salary <br />'Remove sicR. PT IL, <br />a+d,torHolidays ncr <br />D the <br />TaxEmptoyrr,r <br />Contribution, <br />Retirement Employer <br />Contribution�ztculatei <br />tirmlapee'sco trtuc. <br />reflected in gross <br />Total <br />Percentage <br />of Total to be <br />Requested <br />Tota( Requested <br />1001,L: <br />S <br />U' 0Lk <br />S <br />10011L <br />S <br />1001m ; <br />S <br />140 <br />S <br />lOC t <br />S <br />S <br />S <br />S <br />S <br />S <br />S <br />S <br />S <br />S <br />'Ezpuw us 1111j9t tsnulec; unaandt,irvwce auJ rec rpt or Carceted check as piuuf ut pdymen.. <br />•S3tarres must show a breakdown the hours paid by type te.g., regular, stek, vacation). Please note the County will NOT Reimburse for SICK or VACATIOIN <br />,w-te so those must be deducted from the request plor to submitting <br />