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Form Prescribed by Slale Board of Accounts Boyce Forms Systems. Munde. In
/ ~i' RECEIPT. _,,'
~ . DEPARTMENT OF COMMUNITY SEVCES
GENERAL FORM NO. 352 (REV. t DtYI
rtJ.)uJ,..,l , FUND
Cp; MEL IN.. -3 / d- 20J2.L
RECEIVED FROM I CIS ~~W I-Jr-L $ & 3D. tJD
THE SUM OF ~M ~ti. --I1'LL~' ; -------------~~~~"DOllARS
ON ACCOUNT OF 5u- ,r- 0 I - W~brUuJ.. \,A~- 1ufh1.
PAYMENT TY"WMOUNT Ilwtft, 1?a'1L~ G '~
CASH CHECK V 31~ M.O _ t" _ I~A)
a...T c.c./a.c. OTHE~ AUTH ~IGNATURE
N~
1455