Receipt for payment of US poll tax (voting).
Source: Form printed by government of Jefferson Parish, Louisiana in 1910s, filled out 1917. Part of display of old ephemera on wall of cafe in Gretna, Louisiana, photographed by Infrogmation (talk). http://en.wiktionary.org/wiki/File:PollTaxRecieptJefferson1917.JPG
Author: State of Louisiana, Parish of Jefferson