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Greater Pittsburgh Community Food Bank - Monthly Sign-in Sheet
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I, the undersigned receipient, acknowledge that I am eligible to receive USDA and State Food Purchase Program Foods due to the fact that my household income is within the limits which have been explained to me based on 150% of poverty.
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Agency Name: Triumph ChurchMonth & Year of Service: November 2024
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Contact Person's Signature:
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Number in Household (HH)
#		Does anyone in HH receive SNAP (Food Stamps)?Please check if first time receiving food ()# of Individuals in HH who are Legally Disabled# of Individuals in HH who are Veterans
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Name (Print)Name (Sign)Phone NumberAges 0-5Ages
6-12		Ages
13-17		Ages
18-34		Ages
35-59		Ages 60+# Male# Female# Trans.Undisclosed GenderYESNO
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