Client Sign In Sheet Template - For Service More Than 1x/month
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1Month/Year:
CLIENT SIGN IN SHEET (for service more than 1x/month)
client initial columns
(Please note how many people
Receiving
Is someone
Receive
in each age category)
Food
in the
Client Name /
TEFAP
Stamps
Household
Total No.
Head of Household
County of
(Yes or
Zip Code of
(Yes or
Employed?
0 -4
5 - 17
18 - 64
65 yrs
People in
*Declared
1st
2nd
3rd
4th
(Please Print)
Residence
Residence
No)
No)
(Yes or No)
years
years
years
Plus
Household
Race
Tues
Tues
Tues
Tues
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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Parent category: Business