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Today’s Date: Agency Name: Address: Project Contact: ___________________________________________Phone #: E-mail: Quarter: (choose one) Agencies may submit a salary reimbursement request in the last month of each quarter.□ Q1 – Jun., Jul., Aug.□ Q3 – Dec., Jan., Feb.□ Q2 – Sep., Oct., Nov.□ Q4 – Mar., Apr., MayQuarterly Contract Reimbursement Amount: Position Approved for Reimbursement in ContractEmployee NameDates of EmploymentPlease attach verification of employment such as a copy of payroll checks, W-2’s, TEC Employer’s Quarterly Report, IRS Form 941 or an employment contract. Checks will not be issued until verification of employment is received.The deadline for ALL reimbursement requests is April 30, 2021. All requests must be faxed or postmarked by this date. No exceptions will be made for late requests.Please send all reimbursement requests and/or salary verifications to:Sarah McIlroy, Community Treasurer at communitytreasurer@OR mail to 5330 Bluffstone Lane, Austin, TX 78759 OR fax to 512-454-7518 ................
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