Exhibit E - AF-79 Headcount Record.pdf
PDF 60 KB Posted
- Attached to
- ACRTC Food Services RFP 230000000003
- Solicitation number
- RFP 511 230000000003 2
- Issued by
- Allegan County, Michigan
About this file
This is a U.S. Air Force form (AF Form 79) used to document meal transactions and subsistence-in-kind (SIK) entitlements at dining facilities, flight kitchens, or field feeding operations. The form serves as a headcount record that accounts for meals sold and distributed to military personnel. The document contains four columns (A through D) with numbered rows (1-92) for recording individual meal transactions, including personnel name, grade, meal period, social security number, sales amount, and operating charge. The form tracks multiple meal periods, including breakfast, lunch, dinner, and meals-in-kind designations. Summary fields at the bottom of each column aggregate the number of SIK meals, total sales amounts, and operating charges by column and cumulatively across all columns.
The form includes sections for refund data, cash collection reconciliation, and overages or shortages reporting. Personnel completing the document must provide explanations for any refunds issued and discrepancies between expected and actual cash collected. The form requires signature authorization from both the facility supervisor and the person responsible for cash collection. Authorization for use of this form derives from 10 U.S.C. Chapter 40, 37 U.S.C. Chapter 9, and Executive Order 9397. The primary purpose is to verify SIK entitlements, record the number of personnel subsisting at the facility, and account for cash receipts. Social security numbers are voluntarily disclosed but required for personnel to receive subsidized meals at no cost, as they are used to verify entitlement eligibility. Information may be shared with the Department of Justice and law enforcement agencies for investigation or prosecution of violations.
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Text version
HEADCOUNT RECORD Accounts for meals sold in a dining facility, flight kitchen or field feeding
Serial No.
ORGANIZATION OR DINING FACILITY:
DATE:
Meal/Flight Meal Rate For Meal Periods Shown
B/L/D/M Operating Charge for Meals Shown
COLUMN A COLUMN B
NAME Grade Meal Period
Social Security Number
Sales Amount
Op Chg
NAME Grade Meal Period
Social Security Number
Sales Amount
Op Chg
1.
26.
2.
27.
3.
28.
29.
5.
30.
6.
31.
7.
32.
8.
33.
9.
34.
10.
35.
11.
36.
12.
37.
13.
38.
14.
39.
15.
40.
16.
41.
17.
42.
18.
43.
19.
44.
20.
45.
21.
46.
22.
47.
23.
48.
24.
49.
25.
50.
# of SIK Meals from Column
B
Sales Amount from Column
B
$ Operating Charge from
Column B
# of SIK Meals from
Column A
Sales Amount from
Column A
$ Operating Charge from
Column A
$ # of SIK Meals from Column
A & B
Sales Amount from Column
A & B
$ Operating Charge from
Column A & B
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 potential 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 without the SSN, since the SSN is used to verify the entitlement.
AF Form 79, Headcount Record (supersedes previous editions of AF form 79, 1339,463, and 2039)
COLUMN C COLUMN D
from
Column A & B
Sales Amount from Column A & B
$ Operating Charge from
Column A & B
$ # of SIK Meals From Column
A, B, & C
Sales Amount From Column
A, B, & C
Operating Charge From Col A, B, & C
NAME Grade Meal Period
Social Security Number
Sales Amount
Op Chg
NAME Grade Meal Period
Social Security Number
Sales Amount
Op Chg
51.
72.
52.
73.
53.
74.
54.
75.
55.
76.
56.
77.
57.
78.
58.
79.
59.
80.
60.
81.
61.
82.
62.
83.
63.
84.
64.
85.
65.
86.
66.
87.
67.
88.
68.
89.
69.
90.
70.
91.
71.
92.
from Column
C
Sales Amount from Column
C
$ Operating Charge from Column
C
$ # of SIK Meals from Column
D
Sales Amount from Column
D
$ Operating Charge from
Column D
Refund Data Total All Cash Collected $
NAME Grade Meal Period
Meal Type*
Amount Refunded
Less Refunds $ a.
$ Cash Overages/Shortages $ b.
$ Net Cash for Turn-In $ c.
$ Total All
SIK
Meals
Total # of Cash Meals
Total Discount
Rate Collected
Total Operating
Charge
Explanation for Refunds:
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 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 persecuting a violation on potential 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 without the SSN, since the SSN is used to verify the entitlement.
| Number |
| Number |
| B |
| B |
| A & B |
| Sales |
| From Column |
| Grade |
| Security Number |
| D |
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