IMPACT REPORT Family Case Coordinator Monthly Referrals
State Form 47576 (10-96) / IMP 0011
INSTRUCTIONS:
This form is for local office use only - DO NOT send to Central Office.
Name of local office Name of Family Case Coordinator
Date of report (month, year)
SERVICE PROVIDER
AFDC REFERRALS Month Target Actual
FOOD STAMP REFERRALS Month Target Actual
TOTALS
SIGNATURES
Signature of Family Case Coordinator Date signed (month, day, year)
Signature of Supervisor
Date signed (month, day, year)