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~rm Prescribed by State Board of Accounts Boy"" Forms Spt"""', MWlClG. In
RECEIPT
DEPARTMENT OF COMMUNITY SERVICES
GEIIERAL FORIIIIO. UZ (REV. "171
G~~
N2
1684 .
FUND
CARMEL IN.. ~\J..c..- .:l.L""", .20~
RECEIVED FROM~LU.~~.J.. ~AtL~~~\ LL.~ $~
THE SUM OF ~\;:) '\ ~~<l".~~ ='Cct\-"l' .\...,~~ ~-u4-W~~OLLARS
ON ACCOUNT OF gC-Q\ f\~l..<> ~lC~, ~ 1-<:::.\ ~p ~1~u, ~"1-fn- ~
PAYMENT'TYPE 81 AMOUNT ~ -C, ~C'-S ~41 "S U. - q cs--o ~
CASH CHECK_l ~ M.O.
E.F.T
C.C./B.C.
OTHER