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Form Prescribed by Slale Board of Aecounlll Boyce Form. Sy&t8Dlll. Muncie. In
RECEIPT
DEPARTMENT OF COMMUNITY SERVICES
4lERERAL FOIlM 110. SU IREV. '''71
C1~
N2 1652
FUND
CARMEL IN., ~L."'" 0, .2ocl
RECEIVED FROM ~ G.L..''Lt:\~ ~r"~.~ Q~~~"",
THE SUM OF ~')( ~M.~~ \.M.''''''l"J "","Q ~
ON ACCOUNT OF ~U.&\-1Y.-~1
$iQ~.~~
SOLLARS
100
CAS~ CHECK
" ~-a....~J1.\
I S"~OC')M.O
PAYMENT TYPE a AMOUNT
E.F.T
c.c./a.c.
OTHER