Name of Provider _______________________________ TIN/SSN _________________
Week of _____________________________
Keep For Your Records
| Child's Name | Monday | Tuesday | Wednesday | Thursday | Friday | Saturday | Sunday | Totals |
| Hours of attendance: _____
□ Bkfst □ Snack □ Lunch □ Snack □ Dinner □ Snack |
Hours of attendance: _____
□ Bkfst □ Snack □ Lunch □ Snack □ Dinner □ Snack |
Hours of attendance: _____
□ Bkfst □ Snack □ Lunch □ Snack □ Dinner □ Snack |
Hours of attendance: _____
□ Bkfst □ Snack □ Lunch □ Snack □ Dinner □ Snack |
Hours of attendance: _____
□ Bkfst □ Snack □ Lunch □ Snack □ Dinner □ Snack |
Hours of attendance: _____
□ Bkfst □ Snack □ Lunch □ Snack □ Dinner □ Snack |
Hours of attendance: _____
□ Bkfst □ Snack □ Lunch □ Snack □ Dinner □ Snack |
Number served: Breakfasts: ____ Lunches: _____ Dinners: _____ Snacks: _____ |
|
| Hours of attendance: _____
□ Bkfst □ Snack □ Lunch □ Snack □ Dinner □ Snack |
Hours of attendance: _____
□ Bkfst □ Snack □ Lunch □ Snack □ Dinner □ Snack |
Hours of attendance: _____
□ Bkfst □ Snack □ Lunch □ Snack □ Dinner □ Snack |
Hours of attendance: _____
□ Bkfst □ Snack □ Lunch □ Snack □ Dinner □ Snack |
Hours of attendance: _____
□ Bkfst □ Snack □ Lunch □ Snack □ Dinner □ Snack |
Hours of attendance: _____
□ Bkfst □ Snack □ Lunch □ Snack □ Dinner □ Snack |
Hours of attendance: _____
□ Bkfst □ Snack □ Lunch □ Snack □ Dinner □ Snack |
Number served: Breakfasts: ___ Lunches: _____ Dinners: _____ Snacks: _____ |
|
| Hours of attendance: _____
□ Bkfst □ Snack □ Lunch □ Snack □ Dinner □ Snack |
Hours of attendance: _____
□ Bkfst □ Snack □ Lunch □ Snack □ Dinner □ Snack |
Hours of attendance: _____
□ Bkfst □ Snack □ Lunch □ Snack □ Dinner □ Snack |
Hours of attendance: _____
□ Bkfst □ Snack □ Lunch □ Snack □ Dinner □ Snack |
Hours of attendance: _____
□ Bkfst □ Snack □ Lunch □ Snack □ Dinner □ Snack |
Hours of attendance: _____
□ Bkfst □ Snack □ Lunch □ Snack □ Dinner □ Snack |
Hours of attendance: _____
□ Bkfst □ Snack □ Lunch □ Snack □ Dinner □ Snack |
Number served: Breakfasts: ____ Lunches: _____ Dinners: _____ Snacks: _____ |
|
| Hours of attendance: _____
□ Bkfst □ Snack □ Lunch □ Snack □ Dinner □ Snack |
Hours of attendance: _____
□ Bkfst □ Snack □ Lunch □ Snack □ Dinner □ Snack |
Hours of attendance: _____
□ Bkfst □ Snack □ Lunch □ Snack □ Dinner □ Snack |
Hours of attendance: _____
□ Bkfst □ Snack □ Lunch □ Snack □ Dinner □ Snack |
Hours of attendance: _____
□ Bkfst □ Snack □ Lunch □ Snack □ Dinner □ Snack |
Hours of attendance: _____
□ Bkfst □ Snack □ Lunch □ Snack □ Dinner □ Snack |
Hours of attendance: _____
□ Bkfst □ Snack □ Lunch □ Snack □ Dinner □ Snack |
Number served: Breakfasts: ____ Lunches: _____ Dinners: _____ Snacks: _____ |
Information courtesy of the Internal Revenue Service.
