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!>or'" Prescribed by 3lale Board of Accounts BOY,- ',.Iems. MUDc:ie. In RE CE IPT
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GENERAL FORM NO. 352 (REV. 1117)
DEPARTMENT OF COMMUNITY SERVICES
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CARMEL IN" ~ - / .20aL
RECEIVED FROM .e~/)c ~ $$(/;0 ~
THE SUM OF ~~.~~'- . 100 DOLLARS
ON ACCOUNT OF /~-o L S r U1~ ~~~d(~ .
PAYMENT TYPE Be AMOUNT ./ w~ ~ ~ '
CASH CHECK M.O. ~J~ .J~~~
E.F.T. c.c./a.c. OTHER AUTHORIZED ~A~1?~
N2
1591
FUND