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Form prescribed by State Beard of Accounts Boyce Forma Systems. Muncie. In.
RECEIPTGENERAL FORM NO. 352 IRay. 1997)
DEPARTMENT OF COMMUNITY SERVICES
FUND
N2 2048
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CARMEL IN., Q Qa
RECEIVED FROM l
THE SUM OF
ON ACCOUNT OF � %D'� - 1✓ -1c
PAYMENT TYPE & AMOUNT'
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CASH CHECKI`7 M.O
E.F.T. C.C.IB.0 OTHER
SIGNATURE