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Form Prescribed by Slate Board of Accounts Il<>yce Forms Systems, Munde. In.
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CARMEL IN..
RECEIVED FROM
THE SUM OF
ON ACCOUNT OF
PAYMENT TYPE 8< AMOUNT
-. RECEIPT C J
~EPARTMENT OF COMMUNITY SERvrcES
N~ 2271
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cr;~() 20 () g
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Q. 'f - (" r-t.-. DOLLARS
-PS;:~ If - {'71, o~ k Arnelld 100
Cf111 W ~:
E.F.T
C.C./B.C.
CHECr<< ~:5~~o M.O.
OTHER
CASH
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