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Form Proscribed by S!"te B..md..1 Accounts UFormO 8yoto;"0. M~nc!e"I'R:ECEIPT- .
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Q'CHP.:'FI"'L FOAM HO. 315:1 ~REV. '9971
DEPARTMENT OF COMMUNITY SERVICES
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2000
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FUND
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CARMEL IN.. 7 0-', 20.J -'-
RECEIVED FROM ;( /-1 c0(";~C~~~~... 1./) $50{~~/
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TH'E SUM OF ,,-,..~N tk..L,,-~4k~l A1n~----'----------'=-OO'L:'1::-AR.S.--'-'
. I 1/ 100
ON'ACCOUNT OF ~J7-{)~2 '~)f~
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PAYMENT TYPE E!I AMOUNT/'
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CASI-t C"..ECK; . M.a.
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AUTHORIZEO SleNATURE: {."I
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