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Form Preacnl:Jed by State Board at Accounts !:Soyee ."olma ::iyste1ll8. Munce. In
callNItRAL FORM NO. 3152. 'R!;;V. ,....', I
'--" ~EqEIPT ~ "
U DEPARTMENT OF CO'MMUNITY SE~CES
'~- FUND
CARMEL I~ II 20 p~
RECEIVED FROM ~~
THE SUM OF ~~~ ~~~
,/
ON ACCOUNT OF .40 - LJ~ s,.,o
N~ 2161
$ 'loa. 00
~
..-:;:::> DOLLARS
100
PAYMENT TYPE a AMOUNT
CASH CHECKX~/~6R M.O.
E.F.T C.C./B.C. OTHER
;:;9 ~~
~ AUTHORIZED SIGNAT ~
~c;;y~