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Form Prescrlhecl br Stale Board of Account. Boyce P011lUl SyotllDUl. Muncl.. In
RECEIPT
DEPARTMENT OF COMMUNITY SERVICES
GENERAL FORM NO. ISZ lREV. un'
N2 1737
G1e;N~<<-'
FUND
CARMEL IN.. (()~'o~ \ '1 ?Om
RECEIVED FROM ~~'l\{\tFG~ ~~1'Y\.~ $~\"l[c,~~(:)~
THE SUM OF ~,.sy-~oJ..~~~~ '5..t~-f=(\.W~DOLLARS
4 100
ON ACCOUNT OF \\<\~\ ~'?- Q...,~~u.~ ~~~
PAYMENT TYPE a AMOUNT ~C> I U \ c",.., ~.
CASH CHECJC {d. Cd-... M.O
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