2-4 Forrester 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 I oI I w 2, p,),;
Amount Received P.06)
Form of Payment El Check ❑ Money Order
Client Information Forro4e-( �-�..rwf
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
❑ Other
Staff receiving payment Brea k1oIl Po 5 k i Gh
Additional Notes
ForrehA-Pr �(ce -Cier)-,�
I` 5-7017/2110 346
ADAM SCHOENHARDTZ
2 FORRESTER STREET D t
SALEM,MA 01970
PAY TO THE ✓ t �gLrrl M+ 'L_ 1J
ORDER OF pp
0 r DOLLA
CITIZENS
MEMO
2L ?,070L7S 32L. 9681611' 0346
Original Check: Treasurer's Office
Copy: Application File
Scan and email if required