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Form Prescribed by Slale Board of Accounts Boyce Form. :;yslems. MunClO. 111.
QBNERAL PORM NO. 351 IREV. 1 "07)
Q"\. RECEIPT rn
'DEPARTMENT OF COMMUNITY SEf-..'_tlt'Es
N~
2189
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CARMEL IN~ ~ 20~ .
RECEIVED FROM~~~~ ~~~ $ ~oo
THE SUM OF ~~-'--€_#~ ~- ~OLLARS
ON ACCOUNT OF a:.-!-~/.;:yJ~~ ~cOt7-6'.;;' A:i)~s A4Je-4~
FUN.D
PAYMENT TYPE a AMOUNT
CASH CHEC1{. X /1r# M.O.
E.F.T. c.c.fa.c. OTHEF!
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