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Form Preecrlbed by Slale Board of Accounta Boyce OS78181D8. MUDC18. III 0
RECEIPT
DEPARTMENT OF COMMUNITY SERVICES
6ENERAL FORM 110. IS! IRIlV. aHI
Q~
N~ 1671
FUND
CARMEL IN.. ~ ,~ . 200 ,
RECEIVED FROM ~\\,-,-,~~~.J.>\~o~~, , LL-~
THE SUM OF ~ ~t.l~ ~ ~
ON ACCOUNT OF ~-~t ~~ ~~~~ Q) .
PAYMENT TYPE a AMOUNT ~\ '-'-\ "-"'"'--=- ~~ - ~..p.;;.
CASH CHECKj C"II ?S M.O c:-- ~~"
'El.F.T c.c.ls.c. OTHEP
$ f) ~C> .au
--DQ.LLARS
100