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f C~ ~; a G~ L' Date l1 RUC 19J,J !~ No. <br />,~~ ' Received From 9 0 3 A n 1 ~ e l~~l x 0 O <br />ddress <br />Dollars <br />I <br />„ For <br />~, <br />~, <br />ACCOUNT HOW PAID <br />AMT. OF <br />I~ ACCOUNT ~ CASN i ~ <br />Iyy AMT. PAID ~ CHECK <br />' ip <br />LI BAIANCE ' MONEY ~ U <br />-- OUE _ 02JE0 =_- -- <br />[~.Q3tl <br />