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Form PreBe,1bed by Slola Board 01 Aoaounto Boyoe Fonns Sy.lams, Munoie. In.
IiI&NERAL FORM NC, :lSJ: CR;;:V. ISg11
U RECEIP,T ( )
DEPARTMENT OF COMMUNITY SER\1TCES
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2183
THE SUM OF
FUND
CARMEL IN.. 7/.;(,.3 . 20().;:~ (.7
RECEIVED FROM ~d ~"e.,.~, -~~/'-0Z.U 700':3-
.' L:f.' $
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DOLLARS
I I ~ J- t . 100.
ON ACCOUNT OF '. V - I I S - C'),;Z, '. 63 () Aj--~--/I/t3_jJ-,&LA.<?.JL1
V _ I tfG - 0 2... ..t.. 70 V
(5.5'1 L/7"
CHECK. M.O. ./ -~..t/c..-(~~(~
c.c.fa.c OTHER AUTHORIZE;O SlGNYURE;
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PAYMENT TYPE Ii AMOUNT
CASH
E.F.T.