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Farm Prescribed by State Board of Accounts Boyce Form. Systems. Muncie. In.
RECEIPT
DEPARTMENT OF COMMUNITY SERVICES
G ~~'2P.,--
FUN.D .
CARMEL IN.. fY\~d.\20D~
RECEIVED FROM bh1FT"'1n~~ l.~'~ I -:LN.<=-
THE SUM OF \. ~~ ~~~2..rr':::> ~\~I ~.o
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ON ACCOUNT OF f") s -~d-- p\~L-S -t\...~~'i:)
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PAYMENT TYPE a AMOUNT
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M.O.
CASH
CHECK.O?~':;;;~l
c.c./a.c
OTHER
E.F.T.
AUTHORIZED SIGNATURE
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ClBN,ERAL FORM NO. 352 tREY. "lint
N2
2069
$~SD ,<::su
DOLLARS
100