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110= Pr""oJ:ibed by Stat.. Board 01 AOCC\lJlhl Bayce Porma SYltel!ll. 14=8. In
RECEIPT
DEPARTMENT OF COMMUNITY SERVICES
lIEIlERAL FORII NO. 352 IREV. (117)
(},~L-
N~ 1696
FUND
CARMEL IN.. ~~ 11 .200\
RECEIVED FROM ~~ I.. LLC-
THE SUM OF ~w,.".l....~ t-'=1 ~~-
ON ACCOUNT OF 11~ -0, ~~L<::::' D\Y'n~D
$ ~SC).b0
DOLLARS
100
E.F.T
C.C./B.C.
OTHER
AUTHORIZED SIGNATURE
PAYMENT TYPE & AMOUNT
CASH CHECK 3? \"&~.o.