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Form Pr...crlbed by St1ll8 Board of AcCOUIIII Boyce POrlll8 Syeteml, Muncie. In
RECEIPT
DEPARTMENT OF COMMUNITY SERVICES
8EIIERAL FORM IUI. UJ (REV. '1I7l
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Ng 1730
CARMEL IN" 1.'1 - .20.Q.L
RECEIVED FROM IL, 'H-- ~<.cl ~C1,.
THE SUM OF 1'\U'iF ~~~ ~ ~
ON ACCOUNT OF I ot)-O\ ~
FUND
$5leD.O~_
DOLLARS
E.F.T
C.C./B.C.
OTHEP
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PAYMENT TYPE It AMOUNT
CASH CHECI'" Q ~')() M.O