8 Woodbury Court Clerk's Fee City of Salem Department of Planning and Community Development
Check Receipt and Tracking Form
Please complete the form and make two (2) copies
Date Received
Amount Received
Form of Payment Check ❑ Money Order
Client Information
Arts& Culture Land Use Boards
❑ Artists' Row Rent ❑ Planning Board Application Fee
❑ Charlotte Forten Plaza Use Fee ❑ SRA/DRB Fee
❑ Derby Square Plaza Use Fee ff ZBA Fee
Payment received for ❑ 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 &rah ndn (?oSfiGL,
Additional Notes
CLAUDIA PARASCHIV ���
I 22 FOWLER ST
SALEM MA 01970 sI2�/ 53-8411013 I
Date CHECK AiMOR E
Pay to the
Order of 61 rY AAo
Dollars Q P"
' jj�08tjpads i
CREDIT UNION
Lynn,Massachusetts Q194}} ^ i�
For —
' 1: 21138411 ?1: 42 108369u' 015 �� P
Original Check and Form: Treasurer's Office
Copy 1: Client
Copy 2: Application File
Scan and email if required