16 Eden Street Registry of Deeds 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 VDf .00
Form of Payment Check ❑ Money Order
Client Information
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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 ❑ 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 Brennan ti,
Additional Notes
LG F-len 5faef-- ROD Cie
Aysel Yilmazkulas 122
97 Central St Apt 2 s3 rs r is MA
Peabody,ALI 01960-431 S
�1 rl Dade C n
Pay tot�le !1 ge r o � e� $ 105, 00
Order of
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BANK OFAMERICA�%/
ACH Rrr 011000`138
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ISLAND BREEZES'
H.[.ar Clark.
Original Check and Form: Treasurer's Office
Copy 1: Client
Copy 2: Application File
Scan and email if required