11 Felt Street Clerk's 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 1
Amount Received I �
Form of Payment IM Check ❑ Money Order
Client Information 5�C G?�
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 0 ZBA Fee
what service? ❑ Old Town Hall Rental Fee ❑ Peer Review Fee
❑ Security Deposit for Escrow Acct. ❑ Conservation Commission Fee
Other
❑ Salem Ferry
❑ Other
Staff receiving payment �fc n nd n
Additional Notes
l � 511-a crr'S Fee
North Shore Bank 2105
Tinti&Navins,PC 63-7129/2113
Salem Operating
27 Congress St,Suite 414
Salem,MA 01970 a~
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m
PAY Two and NO/100 DATE AMOUNT w
0
TO THE o
ORDER OF City of Salem 09/30/2025 $2.00 a
City of Salem
93 Washington Street
Salem,MA 01970 -
0
AUTHORIZED$*NATURE
0
its 002u05its 1: 21137x29EP: 9951, 397311' I
Original Check: Treasurer's Office
Copy: Application File
Scan and email if required