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74 215 Form
REIMBURSEMENT REQUEST CALENDAR CLAIM QUARTER CLAIM DUE BY CLAIM WILL BE PAID BY Jan 1 to March 31 April 22 May 20 Q1 April 1 to June 30 July 22 Aug 19 Q2 July 1 to Sept 30 Oct 21 Nov 18 Q3 Oct 1 to Dec 31 Jan 22 Feb 19 Q4 AMOUNT REQUESTED Per instructions on reverse side, please attach supporting documentation with this request for payment. COUNTY CERTIFICATION I,______________________________________________, the authorized official of the Commissioner’s Court of PRINT...Show details
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