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Indiana Housing and Community Development Authority <br />LHRDG Payroll Authorization Form - Recipient <br />Recipient: City of South Send <br />Award Number: LD-018-003 <br />Please list all employees and their respective rate of pay that will be utilized on this award. If a rate of pay changes, a new <br />Payroll Authorization Form must be submitted. This form must be signed by the chief executive officer of the recipient and <br />certified by a Notary Public. <br />Hourly Rate of Hourly Fringe <br />Employee Name payBene zt ar <br />Pereentyge <br />1. $ <br />2. $ <br />3. $ <br />4. $ <br />5. $ <br />b. $ <br />7. $ <br />8. $ <br />9. $ <br />10. $ <br />Primary Authorized Signature <br />Signature <br />Typed Name and Title <br />Date <br />Notary Public <br />Subscribed and sworn before me this day of <br />20_ <br />Notary Public <br />Typed Name <br />Seal: <br />My Commission <br />Expires <br />County of <br />Residence <br />