Donated Item Delivery Receipt Form

Records and confirms the delivery of donated items to a participant, with sign-off from staff and the recipient.

Use this template

Name

Nombre

Apellido

Ethnicity

Hispanic/Latino Not Hispanic/Latino

HMHB Program

Client Zip Code

Client Bus Pass #

Bus Pass Type

Weekly Monthly Single Ride

Gas Card #

Company Name & Amount

Gift/Food Card #

Company Name & Amount

Costco or Item(s) Requested and/or Delivered

Welcome-to-the-World Package Requested / Delivery Date

Gender

Female Male Other

Item Value (If Not Previously Listed Above)

Total Value (If More Than One Item Delivered)

Manager Approval

Sign here

Date

Staff Signature

Sign here

Date

Participant's Signature

Sign here

Date

	Column 1	Column 2	Column 3
Row 1
Row 2

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