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Form Prescribed by State Board of Accounts Boyce Forms Systems, Mu..",e. In
U RECEIPT (j
DEPARTMENT OF COMMUNITY SER",,"CES
~.P FUND
-
CARMEL IN.. M ....s 20 t:Jei(
RECEIVED FROM. ~eC::'trV;-LL- ~. ~,LC-
THE SUM OF =d' ~ ~-.L p;.u?;= 4.n>~v<> c:=::",~
ON ACCOUNT OF/39- CJ~ 0;0 4?A:~
. ..
PAYMENT TYPE a AMOUNT
CASH CHECJ< 5,a,~.o.
C7~~
. 11 AUTHORIZED SIGNATURE
E.F.T.
C.C./s.C.
OTHER
ClBHERAL FORM NO. 382 CREV. '''''7.
N2
2290
$ SGJ. t:fO
DOLLARS