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form Preocrlbocl by SllIIe Boord elf Account. Boyce Forma Systems, MUDcIe. In
RECEIPT
DEPARTMENT OF COMMUNITY SERVICES
1l!IIERAL FoaM 110. asz (REV. 1111)
NE
1752
O~L-
CARMEL. IN.. . 0... & s 2~
RECEIVED FROM 0-~
THE SUM OF \W->~ ~....~ 'D~\"J ~ ~ -
~ 100
ON ACCOUNT OF \ ~~-a\ ~ ~'-~ ~~~
FUND
$ 'g)SfO<~
DOLLARS
PAYMENT TYPE "MOUNT ~ -\:-' h~ -.- -
CASH CHECK l ~ M,O
s".. t::>, ~ ~\I..t,~
~.- -
HORI SIGNATURE
ll.P:. T
C.C.{B.C.
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