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# of SIK Meals from Column A&B

NAME
51 52 53 54 55. 56. 57 58. 59 60 61 62.

COLUMN C Sales S Amount from Column A&B Grade Meal Period

Operating $ Chargefrom Column A & B Social Security Sales Amount Number

# ofSJK Meals From Column A,B,&C


Op Chg
72. 73 74. 75. 76 77. 78 79. 80. 81. 82 83

NAME

COLUMN D Sales Amount $ From Column A,B,&C Grade Meal Period

Operating Charge From Col A, R&C Social Security Number

s
Sales Amount
Op Chg

63

84. 85.

64.

65. 66 67 68 69.

86. 87. 88. 89 90. 91. 92.

70. 71.

# of SIK Meals from Column A,B,&C

Sales Amount from Column A.B.&C

Operating Charge from Column A,E,&C

Total All SIX Meals

Total Discount Sate Collected

Total Operating Charge

Refund Data
<*

Total All Cash Collected


Meal Type" Amount Refunded

$ $ $ $
BAS Mealdays

NAME

Grade

Meal Period

Less Refunds Cash Overages/Shortages Net Cash for Turn-In

$ $ $

Explanation for Refunds: *

Total Number of .3K" Cash Meals 1 fealdays Explanation of overages/shortages

Signature and Grade of Facility Supervisor

Signature and Grade of Person Making Collection

PRIVACY ACT STATEMENT AUTHORITY: 10 U.S.C., Chapter 40; 37 U.S.C., Chapter 9, EO 9397, November 1943 PRINCIPAL PURPOSES: Used to authorize and verify the Subsistence-in-Kind entitlement, record the numbers of people subisisting, and account for cash collected. ROUTINE USES: Information maybe disclosed lo the Department of Justice, and to federal, state, local or foreign law enforcement authorities for investigating or presecuting a violation on potention violation of law DISCLOSURE: Disclosure of SSN is voluntary. However, members otherwise entitled to Subsistence-in-Kind will not be provided a meal at no cost withoul the SSN. since the SSN is used to verify the entitlement.

HEADCOUNT RECORD
ORGANIZATION OR DINING FACILITY Meal/fflght Meal Rate For Meal Periods Shown (indicate if meals were sold ala carte)

Accounts for meals sold in a dining facility or feeding

field

Serial No. DATE

B/L/D/M/R/S

ALA
COLUMN A Grade Meal Period

$ $
Social Security Number

t $

Operating Charge for Meals Shown (if ala carte, enter percentage)
Op Chg

$ $

$
$

Percentage:

NAME
1
2 3 4 5. 6 7 8, 9. 10 11. 12 13 14. 15

Sales Amount

* of SIK Meals from Column A

NAME
26 27. 28 29 30 31 32 33 34 35. 36 37. 38 39 40

COLUMN B Sales Amoun $ from Column A Grade Meal Period

Operating $ Chargefrom Column A Social Security Sales Number Amount

OpChg

16.

17 18. 19 20 21. 22. 23. 24 25

41 42. 43 44 45 46. 47 48 49

50

U of SIK Meals from Column A

Sales Amount from Column A

Operating Chargefrom Column A

It of SIK Meals from Column A&B

Sales Amount from Column A&B

Operating Chargefrom Column A&B

* Write in B - Breakfast, L - Lunch, D - Dinner, M - Midnight, R - Brunch, S - Supper To delermine mealdays, multiply the number of meals served by the appropriate meal percentage Breakfast - 20%, Lunch-40%, Dinner40%, Midnight-20 or 40%, Brunch-45%, and Supper-55%. PRIVACY ACT STATEMENT AUTHORITY: 10 U.S.C., Chapter 40; 37 U.S.C., Chapter 9; EO 9397, November 1943 PRINCIPAL PURPOSES: Used to authorize and verify the Subsistence-in-Kind entitlement; record the numbers of people subsisting; and account for cash collected. ROUTINE USES: Information may be disclosed to the Department of Justice, and to federal, state, local or foreign law enforcement authorities for investigating or prosecuting a violation or )0tential violation of law. HSCLOSURE: Disclosure of SSN is voluntary. However, members otherwise entitled to Subsistence-in-Kind will not be provided a meal at no cost without the SSN, since the SSN is used to erify the entitlement. AF Form 79, HeadCOUnt ReCOrd (supersedes previous editions of AFform 79, 1339,463, and 2039)

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