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63-1230 STATE FORMS & INSTRUCTIONS (Continued} 63-1230 DFA 287 (4/80) |

STATE OF CALIFORNIA = HEALTH AND WELFARE AGENCY DEPARTMENT DF SOCIAL SERVICES

FOOD STAMP PROGRAM IDENTIFICATION CARD

issued to

issued Case No

SIGNATURE OF HEAD OF HOUSEHOLD

SIGNATURE OF OTHER HOUSEHOLD MEMBER OFA 287 14/80}

SIGNATURE OF AUTHORIZED REPRESENTATIVE

SIGNATURE OF EMERGENCY AUTHORIZED REPRESENTATIVE

No. of Persons in Household Household Eligible for Delivered Meals

Yes Nof}