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Form Pre,cnbed by State .Hoo.n:1 at Accounts tlCYC9 ronns ::Systems. tl'J.unoe. J.U
1II1lN!.RAL FORtwi' NO. ,0,2- (REV. I g97)
"'\ RECEIPTr ,--,)
U DEPARTMENT OF COMMUNITY SEiwlCES
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2053
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RECElVED FROM
THE SUM OF
FUND
. ~ /;0 20 6 ~
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7l(.~.~~/,{ La-f;ult-j~ .sI~~vJ -CU.
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~ 'HurU-LtiA-ld {~1 )L-'~
. (:/ 100,
ON ACCOUNT OF<t; - 0;2. AbL S !fr1LU1?(LL, .Ji:!J.4cl-:
V ~'tJ - 0 ~ "- <.-( -.e, 'z.. j~) ,,-I" J?~
PAYMENT TYPE 13: AMOUNT v v ..
CAsH CHECK (}O!f.7-CY M.D. ~ J...-i~ ~
I . O'HER . [<' '^:~'''" :1:}"
E,F.T. C.C. B.C.
CARMEL IN.,
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$ ~O~G
DOLLARS
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