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Fodn Prescribed by State Boa.t'd .of Account::'! Boyce......-...TI3 Systems. M:.mde. tn.
U RECEIPT
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~.!:NEFlAl.. FORM NO. 3:!2. ~RE"". 1~97J
DEPARTMENT OF COMMUNITY SERVICES
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PAYMENT TYPE a AMOUNT "
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CHECK (f) -:; =::. M.O.
G,!D--'-=.Pk- FUND, I
CARMEL IN.,rnp,~ 1, 20 Dd--.
RECEIVED FROM ~~'"~~,~ \A ~ .......0 ClAu il'-Q,~\ 0 r- ~)S1
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THE SUM OF ~'-"f.- ~ ,..;;C::l45-o '\'+\1 p.,ll) A-AD ,-~
ON ACCOUNT OF~-"d8-od-.. I
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AU ORIZ€O 51. lATURE
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2058
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CASH
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