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Porm Prescribed by Stale Board of Accounts Boy.... Forms Syotems. Nun...... lD
RECEIPT
DEPARTMENT OF COMMUNITY SERVICES
llEIIERAL FORII 110. 852 (REV. 11171
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N2
1684 '
FUND
CARMEL IN., ~'\.).c... ~L-" ,20~
RECEIVED FROM~LU.~ ~-J.. ~Afl-~~~~ LL~ $~
THE SUM OF \' ~ I;) "'\ ~-.)..,,~~ =ICot\-"l' t\~~~ ~-UwW~-\l>'U~~OLLARS
ON ACCOUNT OF RD-O\ P\ ~\..<> ~ lO\::), R l-c::.\ ~p ~ 10.(:)\ x:.~ ~
PAYMENT'TYPE a AMOUNT ~ -0 \ ~C,-s. ~4 ') -S u. - q S--e ~
CASH CHECK l~ M.O. ~ ~
E.F.T
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