Distribution Date
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Month
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Day
Year
Date
Name:
Distribution Site:
Address:
Number of People in household:
County:
Phone Number
(Signature of Head of Household)
(Date)
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Month
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Day
Year
Date
Authorized Representative: I hereby authorize the following person to pick up food for my household: (Please Print)
Signature of Head of Household
Date
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Month
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Day
Year
Date
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