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à titre de (4) .... ~:_:!)... é~L ........... ................... . . ........ . . .................... ............ .
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pour laquelle il lui a été élivré une quittance n° (5) ~ .A.5.C... .

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 DMINISTRATION DES 1mr-urS
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ffl de la partie YerSame.
'llicle.
ant de la somme en lettres. demeurant à (2) ····················:·····f···············································~················································
if ou nature du versement.
néro et date de la quittance délivrée.
la somme de (3) ...... ~e.yr...J(l~~e~ . .~~--····································
à titre de (4) ...... ~::.!).... ,b................... ..................................................................................
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Le Receveur,