24 Fort Avenue Clerk's Fee City of Salem Department of Planning and Community Development
L Check Receipt and Tracking Form
Please complete the form and make two (2) copies
Date Received ) Jc/
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Amount Received 0 0
Form of Payment I5�Check ❑ Money Order
Client Information c,( FQrf Aver uC
Arts& Culture Land Use Boards
❑ Artists' Row Rent ❑ Planning Board Application Fee
❑ Charlotte Forten Plaza Use Fee ❑ SRA/DRB Fee
Payment received for ❑ Derby Square Plaza Use Fee De ZBA Fee
❑ Old Town Hall Rental Fee ❑ Peer Review Fee
what service? ❑ Security Deposit for Escrow Acct. ❑ Conservation Commission Fee
Other
❑ Salem Ferry
❑ Other
Staff receiving payment $ rerroo Po5fl cii
Additional Notes
4 Fo 0 Aver, ue - 00 C(erfes He
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BOWDITCH AND DEWEY, LLP Citizens Bank 020477
311 Main Street 5 7017/2110 Date Amount
P.O. Box 15156 04/22/2025 *************2.00
Worcester, MA 01615-0156
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Pay: Tivo and 10/1 I l Dollars _ V
VOID IF NOT CASHED WITHIN 120 DAYS
BY
Pay City of Salem
To the
Order of BY__
'11T✓O SIGNATURES REQUIRED
FOR AMOUNTS
EXCEEDING$25.000 00
ii'0 2 0 4 7 7 0' 1. 2 L LEI ?[] L 7 51. L 3 3 0 21. 5111311 111
Original Check and Form: Treasurer's Office
Copy 1: Client r
Copy 2: Application File
Scan and email if required