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9 <br />ftescribed by State Board of Accounts <br />To: (Title of Officer) <br />0 <br />REPORT OF COLLECTIONS <br />General Form No. 362 (1968) <br />0 <br />Indiana. <br />(Governmental Unit) (County) <br />Collections for Period 19— to 19 <br />DESCRIPTIONFund <br />to be Credited, <br />Amount <br />:j <br />4 <br />TOTAL AMOUNT COLLECTED <br />I hereby certify that the foregoing is a true and correct report of collections due the above named governmental <br />unit for the period shown. <br />Dated this day of 19 <br />NOTE <br />This is not to be used as a receipt for collections. (Signature) <br />The official to whom the report is made must <br />issue an official receipt for the collections re- <br />mitted. (Title of Officer) <br />:7 <br />