CHECK 
NUMBER 
DATE 
CHECK IN FAVOR OF, OR 
DEPOSIT ON ACCOUNT OF 
Amount b'r ought forward, 
} 
t * ^ ' . fcZT', 
fc XDM%!> 
i % 
Amount forwarded 
OBJECT 
OR 
VOUCHER 
NUMBER 
AMOUNT OF 
CHECK 
%h(> 
oo 
CHECK 
PAID 
BALANCE 
a 3 
7 
AMOUNT OF 
DEPOSIT 
0 0 
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