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Form Prescribed by Slate Board of AcCOUDta Boyce Forlllll SYBI8IDB. MUDcle. In
RECEIPT
DEPARTMENT OF COMMUNITY SERVICES
SENERAL FORM NO. IIZ (REV. IBM'I
N2 1833
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FUND
18 20(:) I
CARMEL IN..
RECEIVED FROM ~d\<:::>) .r ;;L ~
THE SUM OF \~o ~~C> ~w ~~~ ~~~~~~~~
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ON ACCOUNT OF 1 LJ-ti -~ 2 ~11A,t ~ri) a 9 G:, ~~
~ -b l IDP ~ "S c..w... ~
$.:2, ~{)S.ba
DOLLARS
PAYMENT TYPE III AMOUNT
a~ ~=.l \
CASH CHECyA '?;;!l -:; M.O
'E.....T C.C./B.C.
OTH'EP
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