26 Winter Street ROD 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 0 Q �� � _�o
Amount Received (C}5, d Q
Form of Payment UrCheck ❑ Money Order
Client Information
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 J@ 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 breoll qn PpS¢,,
Additional Notes
5105,00 — Roo F-ee '-swpfer 64COP-f
VERIFY THE AUTHENTICITY OF THIS MULTI TONE SECURITY DOCUMENT. CHECK BACKGROUND AREA CHANGES COLOR GRADUALLY FROM TOP TO BOTTOM.
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PAY TO THE
ORDER OF Drawer. tender Bank
-DRAWEE: SANTANDER BANK,N.A.ISSUED BY: SANTANDER BANK,N.A. AUTHORIZED SIGNATURE
04 244043116 1: 23 L37 269 0: 767S7637 LIB
Original Check and Form: Treasurer's Office
Copy 1: Client
Copy 2: Application File
Scan and email if required