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Form Prescribed by Stale Board of Accounts Boyce~s Systems, Muncie. In.
U' , RECEIPT' ( j
. 'DEPARTMENT OF COMMUNITY SERV~S
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Ol!:NEItAL FORM NO. 352 CR~V. 1091)
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2121
FUND
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RECEIVED FROM k:;k""f:Jt-~ ~. ~J3()-
THE SUM OF (Y/L(~<-/(^-Ula~~d/"-A:tj ~--
ON ACCOUNT OF C? '1.-.6;2. ..:Dr ~1{P1If.d / AbL S
PAYMENT TYPE & AMOUNT ~ ~~ (~:/?;/~(~{::-D . 5"+Jt3~{ 8~
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CASH rA CHECK':t::J ':> ~M~'.30 ~
E.F.T C.C./B.C. OTHER AUTHORIZED SIG URE
CARMEL IN.,