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Form Prescribed by 3tato Boord of AccoUl1ts Boy... Forma 8Tllama. MWld.. In
RECEIPT
DEPARTMENT OF COMMUNITY SERVICES
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8EIIERAL FORII 110. 352 (REV. 18971
07~l.-
N~ 1573
FUND
CARMEL IN.. mp\i ~7~ .20'0 \
RECEIVED FROM 'b~t::~W\~~ \~~
~~ ~
THE SUM OF tS~ ~=- I~
ON ACCOUNT OF- ,.LP,<Q" Of'- LJ....~c.'-A~~~'-
Lo4-n\ ~p
$/0(:),0""0
DOLLARS
100
b~I-A-S~
PAYMENT TYPE & AMOUNT
E.F.T
OTHER
~.~~
. UT 'ZED SIGNATURE
CASH
CHECK ll~ C,
c.c./a.c.
M.O.