20 Williams 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
Amount Received
Form of Payment ff Check ❑ Money Order
Client Information Q Witt «!i9 5
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 [2� 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 �(etiiq rl PC) 5}01
Additional Notes
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LYNN J.MCMURRY 2113 5678
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THOMAS J.McMURRY J�
20 WILLIAMS STREET DATE
SALEM,MA 01970
PAY TO lw IT 4 J� J 4 2Y7r1 2 00
THE ORDER OF
DOLLARS
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42LL37L5731: 0820 38L 2119 5678
LOOK FOR FRAUO-DETERRING FEATURES INCLUDING THE SECURITY SQUARE AND NEAT-REACTIVE INK.DETAILS ON BACK.
Original Check:Treasurer's Office
Copy: Application File
Scan and email if required