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Fona Preecribecl by Slate Board of AecOIlJlII Boyc8" Forma SYlIlllIIl8, MlIJlcla. III
RECEIPT
DEPARTMENT OF COMMUNITY SERVICES
GENERAL FOllM NO. JU ellEV. I tI,l
~'--- FUND
CARMEL IN.. ~ I 1") .20~
RECEIVED FROM ~~ - D ~A ~ ~, )Dl? ~ ~
THE SUM OF~V"o~~. ~ o~-t\u,,~ ~,~~ DOLLARS
ON ACCOUNT OF 3't)-o \ ~~L~ -~~~a Wo~
N~
1520
PAYMENT TYPE a AMOUNT
CASH CHECK 109 ) 9- M.O.
E..F.T. c.c./a.c. OTHE~