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Form Prescribed by Stale Board of Acco1mI8 Boyce ForIZUI ByellllDa, MUDcIe. lD
RECEIPT
DEPARTMENT OF COMMUNITY SERVICES
GEIIERAL ~RIl NO. ISZ IRIlY. 111tY1
Q,~-
N~
1857
FUND
CARMEL IN" ~ <i 20~
RECEIVED FROM - 1JlFMIC<>L~"N C"',,~~
THE SUM OF~~-- J....~ ~'"i ~'" %.-.
ON ACCOUNT OF 5-0\ ~~L~ ~.~
~{e<~~
-=- ~
~ .~"O~ ~=.
$ f;,S-C ,0 a
, DOLLARS
100
PAYMENT TYPE . AMOUNT L~:~.
CASH CHECK ~~O~ M.O
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