Client Sign In Sheet Template

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CLIENT SIGN IN SHEET
Date:
(Please note how many people in
Is someone in
each age category)
Zip Code
Receiving
Receive
Total No.
the Household
Client Name/ Head of Household
County of
of
Food Stamps
TEFAP
0 -4
5 - 17
18 - 64
65 yrs
People in
*Declared
Employed?
(Please Print)
Residence
Residence
(Yes or No)
(Yes or No)
(Yes or No)
years
years
years
Plus
Household
Race
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
*You are not required to answer these questions to receive food assistance. However, your options for this field are: Black, White, Asian, American Indian, Other

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