6 Botts 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
07 /[alzaz S- l
Amount Received J % Q0
Form of Payment 01 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
Payment received for ❑ Derby Square Plaza Use Fee ® 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 renridr7 PoO-10,
Additional Notes
G�ur erh-s Fie
53-7OW2113 2 3 0 11
CHRIS DRUCAS ATTORNEY AT LAW
CLIENT'S FUND ACCOUNT
d PAY TO THE �
fJRDEROF $
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— —— -- — - DOLLARS
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1: 2 L L 3 70 5 58i: 08 9 900 5 901-on 2 30 L
Original Check and Form: Treasurer's Office
Copy 1: Client
Copy 2: Application File
Scan and email if required