MONTHLY DISTRIBUTION REPORT

DATE COVERED _________________

Each agency is required to submit a monthly report on the number or people being served and the amount of food being distributed. This form must be completed and returned to Second Harvest Food Bank by the 10^th day of the following month.

ORGANIZATION NAME: ______________________________________________

MAILING ADDRESS: __________________________________________________

TELEPHONE: _________________________

CONTACT NAME ____________________________

Records are kept on file for each individual served? ___ Yes _____ No

Section 1. AGENCIES DISTRIBUTING BOXES

____________Number of households receiving food boxes

____________Number of individuals served by the food boxes

* We want to know how many boxes you gave out that month and how many individuals total were served by your food box. Example if you gave out to 2 households and each household had a family size of 4. Then you served 2 households and 8 individuals.

Section 2. ON SITE PROGRAMS

__________Average number of individuals at each meal (a meal is breakfast, lunch, dinner or a snack)

__________Total number of times served (during this reporting period)

* We want to know how many times’ food was served at your facility. Example, If you were open 20 days this month and served 3 meals a day then your total times served would be 60.

Section 3. USDA AGENCIES

____ Onsite

____________LIST THE NUMBER OF RECIPIENTS THIS MONTH (1 recipient = 1 person)

___Pantry

__________LIST THE NUMBER OF RECIPIENTS THIS MONTH (1 recipient = 1 family)

* If you are a pantry and also serve onsite please fill out both sections of this report. For questions contact Katie @ 477-4053.