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,,~ c",,'- '0" c" '.. c,"" ',", ~, ~,.c ~ ,-~ .--~",~.." --"( f -.,. " ,', ......, --".~', -. " -.. -. C.. c_ "" h. . Form Prescribed by State Board a! ACc<n..nlS Boyca Fo~ystem.sl Muncla. In. - ; . ~~,QEIPT DEPARTMENT OF COMMUNITY SERVICES 'c... ..-...._,.,-'U- "-~ ,......... ._..~.. "._ ~'. ':' ....:.< ._, _~ .,..-..,.__ ., 'L_'_"'.~~ GENERAL FOIlM NO. :l~2 {R:=:\I. 19517) ;! 'j j ',l 1 'I j j N2 2547 .A1LtJA..,.4.J FUND CARMEL IN., ',_ ~-;3 - ;:.;:/ , 2 O/,'-~- ~ } ':I"" ~..J.' ;( ! . d:... /"1' ,;:' _ .J k-(..~Y1::-L.~'1.:.~t:'l/.. ,/~l-tG--&:t!;tt~.i::'~~'f./~ ..--"1'.1 "-7/i 0 ~.:.-. $ /.:7/ U /7>CJ .1 i i RECEIVED FROM THE SUM OF /'/ ". J/~'~ ..I' :,~.;;.~.?':~:.~' /~~n}i- ,_~~"...... . /c,:::;.l.?-"(,A;:~;y(. ,(i.--t.<--'J{,4-C,!..-Ltf/l( .I:.t.{/(:~?[A~l // (/ ,/ /; '! ~... "W" ..:;G.~ i/.~// . ------.gObl::;;-ARS '00 ...'/' (/ ON ACCOUNT OF / / ,} ~ /~ "'''/' -7-. ( .. . {,--, .....' :::~: C. 1~~1 ..,...J ........-JI ,. .t:.;r,;' PAYMENT TYPE e. AM~UN'/' ('_-<,2~#v~' ,k/ ,/J '7 (" r) ; f/ /1 i. ,/' , 0.... .{ t> "'a ..... CASH ' C ECK' ""I . o. 71 M.O f~:':~:? ""-/,~,<1.".o'~ ,/',...-'(_.rL~I."'1"'U (,J i'" / .s;,d~ .E.F.T. C.C./B.C,. OTHER .-'l ,j 1~C:::0.~.t~_~~/ I AUTHORIZEO 5!GNATUR,Ec"/ :" . ;:;:.? L.' ,I if,,-l-"':',i"\J~':':"i'.;-.-::~;;,,;.,'i':::~,;,~,,~-;;;i.'';':~~:')~,-'~j~~~.~.t~':~r~-'-',:;,';:.:i.:..~~~,~;~~ci,i:1,:t~".:.~i!::J //' (...,-t:r:.i;t:.-,-&G-<::-.. ;J' ;.,~,,';::~)~;~";"; ~'~;-..::.:" ~i~'"~(;;'It:i'J:!'.""i.J~.~l-: , . -,:~.:...!, ~~vr.:~:-~,'" ; ,.;,i-" :':l'~,~';;;;~":-';""':bl;'~;'~'\.-"'" ~"'~'i;c~~~1";(',::-.\~":;;_~~~'i.I.I"";i.of"r"J;"~' ,'.""""~"i'~' i,..'j""