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 State ZIP Code
County
Person Completing The Form*
First Last
Email*
Contact Phone*
Report All Service For The Month
Our Agency Is*
Total # of Families Receiving food assistance from your program
Total # of Individuals Receiving food assistance from your program
Total # of Families Receiving Help for the First Time This Month
Of The Individuals Reported
Children (Ages 0-18)
Adults (Ages 19-55)
Seniors (Ages 56 and older)
Total Individuals (Ages)
Ethnicity
Hispanic
Caucasians
African Americans
Asians
Other Ethnicity
Total Individuals (Ethnicity)
Meals Served
Total Number of Breakfasts
Total Number of Lunches
Total Number of Suppers
Total Number of Snacks
Total Number of Meals Served
Other Food Donors
Non-Food Bank Sources
Please indicate any other sources of food your agency receives from outside sources.
Name
This field is for validation purposes and should be left unchanged.

Report All Service For The Month