Monthly Agency Report Monthly Agency Report Please submit report by the 5th of each month. Reports not received on time will result in product hold until reports are received. Reporting Month & Year*Name of Agency*Account Number*Agency Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code CountyPlease Make A SelectionHardinJasperJeffersonNewtonOrangePolkTylerSabinePerson Completing The Form* First Last Email* Contact Phone*Report All Service For The MonthOur Agency Is*Please Make A SelectionFood PantrySoup KitchenGroup HomeShelterResidential CenterDay CareSnack ProgramOtherTotal # of Families Receiving food assistance from your programTotal # of Individuals Receiving food assistance from your programTotal # of Families Receiving Help for the First Time This MonthOf The Individuals ReportedChildren (Ages 0-18)Adults (Ages 19-55)Seniors (Ages 56 and older)Total Individuals (Ages)EthnicityHispanicCaucasiansAfrican AmericansAsiansOther EthnicityTotal Individuals (Ethnicity)Meals ServedTotal Number of BreakfastsTotal Number of LunchesTotal Number of SuppersTotal Number of SnacksTotal Number of Meals ServedOther Food DonorsNon-Food Bank SourcesPlease indicate any other sources of food your agency receives from outside sources.NameThis field is for validation purposes and should be left unchanged.