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Form Prescrlbed by Stele Board af Accounts. Boyce Ferms Syslems, MUllete. 111.
U RECEIPT U
DEPARTMENT OF COMMUNITY SERVICES
GENERAL P'ORM NO. 352 IREV. IIUI71
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N2
2336
FUND
(e/51 ~;z-> 20
t f .-
RECEIVED FROM C -A ~t..A1A-J:;f-t~ LL ~ $ 3 s-o -
~. () L J~ /1/'C'
THE SUM OF '--I~~/ f;- y- /~OLLARS
ON ACCOUNT OF I. '5-02- A- bL:> A--f1u..<<-.? 100
PAYM'NTmEOAMOUNT ~. 6-=f~ ~ ~~ -;r
CASH CHECi51/-'-I ;/ M.O. . ;?f~4~
E.F.T. c.c.fa.c OTHER AUTHORI%EO SIGNATURE -:;
CARMEL IN.,