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Form Prescribed by State Board of Accounts Boyce Form. Systems. Muncie. 111.
U" RECEIPT ('j
, DEPARTMENT OF COMMUNITY SE~CES
QINEftAL FORM NO. 3!52 lAEV. 1007)
N~
2378
@?/Jt!?'/.c:c / FUND
CARMEL IN., /zIj2). o?~ . 20 Oa.
RECEIVED FROM ~~~ 650, Db
THE SUM OF ---? <:/~-V+~ cyr>"'~,>, =-~ :OLLARS
ON ACCOUNT OF /73'-~ A~~.s AmeAP'" 0
PAYMENT TYPE a AMOUNT ~...?<z,/-'C'4!-'V'~ e6t.. ~. ../9
CASH CHEC~.)('~3-33-;;o.
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. c' .:?} 6" .....
AUTHORIZED SIGNA RE
E.F.T
C.C.fB.C
OTHER