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.
Phone
This field is for validation purposes and should be left unchanged.

Dial 2-1-1 for free, bilingual information and referrals for food assistance and other health and human services.

The mission of the Texas WIC (Women, Infants & Children) program is to improve the health of low-income women, infants, and children up to age 5 who are at nutritional risk.

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Southeast Texas Food Bank
© 2021 · All Rights Reserved

Tel: 409-839-8777
Toll Free: 844-356-9084

3845 S. ML King Jr. Parkway
Beaumont, Texas, 77705-4114

The Southeast Texas Food Bank is an Equal Opportunity Provider.

Southeast Texas Food Bank is a 501(c)(3) non-profit organization.

Did you know that a $10 donation can help provide up to 40 meals for desperate people in your community? Rest assured, that every penny of your donation will be stretched to it’s maximum effect. By making a donation, you are helping to ensure that hungry children in Southeast Texas are adequately nourished, that none of our senior citizens are forced to chose between medicine and food, and that every family facing a crisis can at least have the assurance of food on the table.

Your gift goes a long, long way!

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