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Form Prescrlbed br State Board of Accounta BOVcr S1'8lema. M""cH.1II RECEIPT U
DEPARTMENT OF COMMUNITY SERVICES
&/V\eJa I
CARMEL IN..-bb\I. 110 ,~DefD I
RECEI~ED FROM -B(fUY)~r ~ (IV 1 tOy
THE SUM OF c:s{/~ ~W Renfl u-o /UrV
.
FUND
ON ACCOUNT OF
01
~,
PAYMENT TYPE a AMOUNT
CASH CHEC~ M.O
E.F.T c.c./a.c. OTHE~
URERAL FORI/ NO. !SJ IRIV. '''71
N2 1781
$Ia[) ~
DOLLARS
100