Free 45531.FH11 - Indiana

REPORT OF REPAYMENT - __________________________ EXPENDITURES - APPROVED DISTRICT PLANS - TITLE __________________
State Form 45531 (R2 / 10-05) / FM 0413 Approved by State Board of Accounts, 2005

County

Date (month, day, year)

CASE NUMBER 1

CHILD'S NAME IN FULL 2

RECEIPT (FM FORM 37) DATE 3 NUMBER 4 AMOUNT 5

TOTAL OF REPAYMENTS DISTRIBUTION: Attach white and canary copies of FM 0411 and white and canary copies of FM 0412. Send to : DEPARTMENT OF CHILD SERVICES 402 West Washington Street, Room W364 Attn: Account Clerk Indianapolis, IN 46204 Pink copy - County File