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Form PrBiElcl"lbed by State Bom-d of Accounts Eoy-ce Forms Systemll, MunCie. In
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CARMEL IN.,
RECEIVED FROM
THE SUM OF
ON ACCOUNT OF
PAYMENT TYPE a: AMOUNT
CASH CHECK
E.F.T.
c.c./a.c.
/', . RECEIPT (-.
~DEPARTMENT OF COMMUNITY SER~ES
FUND
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4-S- O~ A-J::LS
g.e;"II!:AAL. FORM HO. 3!1~ {R~""_ I QQ7)
N:2 2032
$ 7 It? ,s!--'
tJOLLARS
100
AUTHORI- SlGNA"fURE
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