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Form Prescnbed by State Board at Accounts tsoyce Yorms ::systems. MUDC1e. m
"BNERAL FORM NO. 3~Z (REV. Ilit97l
. ,-- RECEIPT Q
DE~TMENT OF COMMUNITY SERVICES
N~
2179
~~n:e-/ FUND
CARMEL IN., VU~O;>O( 20~
RECEIVED FROM 7/Je ~r~/1 .?ea/7J
l../
THE SUM OF ~~~~ o/~lT2) ~OLLARS
ON ACCOUNT OF 1#7 k ~ /I/;sler-i ZJe~'- k-&;rc4,-A.~1 ~/1-k-
PAYMENT TYPE III AMOUNT JOa - ~ A-...oL....5 A/T)e/1~
CASH CHEC,X 4l:9J "O~THE. ?/~
E.F.T. C.C. S.C
$ 8..G2J. c:; 0