Issued to Prisoner 55829 in Lwow Ghetto
Front: Tan form with printed information in a list on the lefthand side (eight bullet points) and information written in blue ink in printed boxes on the righthand side. A blue oval stamp with the Star of David on the lefthand side.
Back: Printed information in a list on the lefthand side (bullet points 9-12) and information written in blue ink on the top box. Purple stamp in middle. These pre-printed forms were used for determining an individual's work in the Lwow Ghetto.