Free 45272.pdf - Indiana

RECORD OF MONTHLY TIME
State Form 45272 (R / 3-96) / FM 0918

Month/year

County

Office

INSTRUCTIONS Each IV-D paid employee is to enter the hours worked on Title IV-D related activities for each paid working day. Enter "S" for sick leave, "V" for paid vacation, and "H" for paid holiday. Weekends and unscheduled work days should be left BLANK. Each employee is to sign the certification at the bottom of the form at the end of the month. Retain this form with county copies of the CSB monthly reimbursement forms, State Form 24221 / FM 0919 and State Form 24220 / FM 0920. DATE EMPLOYEE #1 EMPLOYEE #2 EMPLOYEE #3 EMPLOYEE #4 EMPLOYEE #5 EMPLOYEE #6 EMPLOYEE #7 EMPLOYEE #8 EMPLOYEE #9 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31.

I certify that the above hours represent only Title IV-D work and are true and correct.
Signature of Employee #1 Date Signature of Employee #2 Date Signature of Employee #3 Date

Signature of Employee #4

Date

Signature of Employee #5

Date

Signature of Employee #6

Date

Signature of Employee #7

Date

Signature of Employee #8

Date

Signature of Employee #9

Date