Proxy Letter Template

Proxy Letter

For: _____________________________________________________

(Pantry Name)

Date: ______/______/__________

This is to certify that I, _______________________________________

(Clients name)

give my permission to _______________________________________

(Proxy Name)

Allowing them to pick up my food box.

This is for (please check one):

This month only

Any month

I live at ___________________________________________________

(client’s address)

*Must send proof of residency with proxy.

Number of people in household by age:

____60+, _____18-59, and _____ birth to 17 for a total of ____________.

Signature: __________________________________________________

(Client signature)

Proxy Name: _______________________________________________

(Please print)

Signature: _________________________________________________

(Proxy signature)

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Parent category: Legal