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P'~ibedbY S;~~"~~~d ofAc~~ts. :B~Yee.FQrms SY9tem~'. Munde.!.;'!' . .. .. """. ".".:., . ~ARTM~~tt: ~~~:~~;NIT; SERViCQ ~ Gi EN E;Il.l. ' .rOfUA NO. :J!II~ .IRR;V~ -,gBJ:I' 114.0 /'") I . C.-cI,':n.>'ZA:...c...-- ~ y/' >'...~ -1 , --('.,....71~_.e:~~0 "UT~ORj:mC/Ii'iGNATUf!E' . './. .. . V. '!".~ ~AA' N~ 2566 FUND ... CARMEL IN.. ./) ,._, ,", ',.;7' (j .20 (J ::) R ECEIV ED FRO M ,!!1u.(~j /:3u~V..-a Ii ,.,.C~~:.~~. (;'t~ii6L~/'/(_ /J / ',I it . ttf ,,' 1.1 . V ,/ _ /' . .A -::.,f .. " ~~~.?"J.VL-.t.-l Il.6<A~~ AU-.r.4.- V1,' .""#~ .-'--:-- . / tf :f ON ACCOUNT.'OF 5/-0:;' /-1-- /) L S " . '."".;. <". \ .... -':!... .1: l ,.,..-..- $ C'>:\:::;; /~7';7V THE SUM OF ~QO.LLARS 100 F'AYMENT.TYPE III AMOUNT . ,/' . ,r' (;.;; ,.J CASH. CHE,:b~ /::? E.F.T. c.c.{s.c OTHER