COLUMN C# of SIK Meals
fromColumn A&B
SalesAmount fromColumn A&B
NAME
51
52
53
54
55.
56.
57
58.
59
60
61
62.
63 «
64.
65.
66
67
68
69.
70.
71.
# of SIK Mealsfrom Column
A,B,&C
<*
Grade
Sales Amountfrom Column
A.B.&C
S
MealPeriod
OperatingChargefrom
Column A & BSocial Security
Number
S
Refund Data
NAME Grade MealPeriod
$
SalesAmount
Operating Chargefrom Column
A,E,&C
MealType"
OpChg
S
Amount Refunded
$
$
$
Explanation for Refunds:
*
Signature and Grade of Facility Supervisor
COLUMN D# ofSJK Meals Sales AmountFrom Column From Column
A,B,&C A,B,&C
NAME
72.
73
74.
75.
76
77.
78
79.
80.
81.
82
83
84.
85.
86.
87.
88.
89
90.
91.
92.
Grade
Total All SIX Total DiscountMeals Sate Collected
Total All Cash Collected
Less Refunds
Cash Overages/Shortages
Net Cash for Turn-In
Total Number of •.Cash Meals 1
$
MealPeriod
OperatingCharge FromCol A, R&C
SocialSecurity Number
$
$
TotalOperatingCharge
s
SalesAmount
OpChg
$
$
$
$
3K"fealdays
Explanation of overages/shortages
BASMealdays
Signature and Grade of Person Making Collection
PRIVACY ACT STATEMENTAUTHORITY: 10 U.S.C., Chapter 40; 37 U.S.C., Chapter 9, EO 9397, November 1943PRINCIPAL 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 lawDISCLOSURE: 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 field Serial No.feeding
DATE
B/L/D/M/R/SALA
$$
t
$
COLUMN A
NAME
1
2
3
4
5.
6
7
8,
9.
10
1 1 .
12
13
14.
15
16.
17
18.
19
20
21.
22.
23.
24
25
Grade MealPeriod
U of SIK Meals Sales Amountfrom from
Column A Column A
Social SecurityNumber
S
* Write in B - Breakfast, L - Lunch, D - Dinner, M - Midnight, R - Brunch, S -40%, Midnight-20 or 40%, Brunch-45%, and Supper-55%.
SalesAmount
OperatingChargefromColumn A
OpChg
$
Operating Charge for Meals Shown(if ala carte, enter percentage)
$
$COLUMN B
* of SIK Meals Sales Amounfrom from
Column A Column A
NAME
26
27.
28
29
30
31
32
33
34
35.
36
37.
38
39
40
41
42.
43
44
45
46.
47
48
49
50
Grade
It of SIK Meals Sales Amountfrom Column from Column
A&B A&B
$
$ Percentage:
$
Operating $Chargefrom
Column AMealPeriod
$
Supper To delermine mealdays, multiply the number of meals served by the appropriate meal percentage
Social SecurityNumber
SalesAmount
OpChg
Operating $Chargefrom
Column A&B
Breakfast - 20%, Lunch-40%, Dinner-
PRIVACY ACT STATEMENTAUTHORITY: 10 U.S.C., Chapter 40; 37 U.S.C., Chapter 9; EO 9397, November 1943PRINCIPAL 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 toerify the entitlement.
AF Form 79, HeadCOUnt ReCOrd (supersedes previous editions of AFform 79, 1339,463, and 2039)
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