2 Cedar Street ROD Fee City of Salem Department of Planning and Community Development �
Check Receipt and Tracking Form
Please complete the form and make one (1) copy
Date Received
Amount Received /0
Form of Payment Check ❑ Money Order
Client Information CN r of ( r
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
what service? ® Old Town Hall Rental Fee ❑ Peer Review Fee
❑ Security Deposit for Escrow Acct. ❑ Conservation Commission Fee
Other
❑ Salem Ferry
IX Other
Staff receiving payment
Additional Notes
FRANK WOLFORTH 3157
PAULA WOLFORTHJ
2 CEDAR ST 51411Wll3
SALEM,MA 01970 ?� ��,fir— Al
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Pay to the
Order of ='�l f�C/o �S GU I` `� 11 -i� �3p��� SIxos
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Digital Federal
• Credit Union
www.dcu.org
For
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c. 2 L L 39 LB 25c.■ 1106646 ills
3157
MLAND&qEEMS-
Original Check:Treasurer's Office
Copy: Application File
Scan and email if required