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Form Prescribed by State Board 01 Accounts Boyce Forms System., Munde. In.
GENERAL FOftM NO. 3~Z tREV. Ilunl
~ RECEIPT ~
U DEPARTMENT OF COMMUNITY SE~CES
N~
2346
ef;k-?1/.A-...c.--R FUND
CARMEL IN..re:: 20~
RECEIVED FROM,k?~/ .~ $;;Z.4--6:-~~ $ 36~. 00
THE SUM OF ~,~~. H1rc:oy--n>,,{~~DOLLARS
~ 9 100
ON ACCOUNT OF '5' - ~ ~.J:Xs ~fl)en/ C~n... i-n~b:3-,L;~
PAYMENT TYPE a AMOUNT
CASH CHECI<'X7~ M.O.
-'-z::::.;;7f-
~./~
. AUTHOP.I~ SlGNATU+
E.F.T.
c.c./a.c
OTHER