2-4 Forrester 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
Form of Payment ® Check ❑ Money Order
Client Information 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 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 C�i1040 ppt kr ch
Additional Notes
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ADAM SCHOENHARDT j f
2 FORRESTER STREET DATE
SALEM, MA 01970
PAY TOTfNF
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DOLLARS EI
CITIZENS jNWP
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!1: 2LL070L751: 1324496816110 0P. 7
Original Check: Treasurer's Office
Copy: Application File
Scan and email if required