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""'m Preecrtbecl by 3tate Board of Accow1ls Boyce Forms STat-. 111_ lD
RECEIPT
DEPARTMENT OF COMMUNITY SERVICES
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UIIERAL FORII 110. au tREY. '1171
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N2 1687.
FUND
CARMEL IN., [J- ,;< f1 .20aL
RECEIVED FROM ~~)
THE SUM OF _'M'- ~-=
I -J- 100
ON ACCOUNT OF 9f-o/ ..kbL ~ ~ W~
A ~
$~
DOLLARS
PAYMENT TYPE eo AMOUNT /.
CAS 1-1 CHE~_ ?/Ot'..3 M.O.
E.F.T
c.c./a.c.
OTHER
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AUTHORizeD,. NAT~