Monthly Statistical Report for THE FOODBANK, INC.

For the Month of 20

Complete appropriate Statistical Sections. Reports must be submitted to the foodbank no later than the 5th of the month following the month to which the report pertains.

Name of Agency:

Check here if any new information

Address: City:

Zip: County:

Phone: Fax: Email:

Name of Person Completing Form:

Food Pantry: A part of a foodbank network that distributes food and grocery products to low-income households, including food from sources other than USDA, to relieve situations of emergency and distress. It is housed in a standing facility that distributes commodities, among other food and grocery products, on a regular basis.

FOOD PANTRY Statistical Section

	HOUSEHOLDS		TOTAL
	With Minor Children	Without Minor Children
A: Number of Households
B: Number of Seniors Served (age 60 & older)
C. Number of Adults Served (age 18 - 59)
D. Number of Children Served (birth - 17)
E. TOTAL Number of People (B+C+D)
TOTAL Number Receiving Food Stamps

Meal Site: Provides meals to people in need.
Shelter: Provides nights of shelter to homeless people, run away children or victims of abuse.

MEAL SITE and/or SHELTER Statistical Section
A. Number of People (head count) Served:
B. Number of Meals (plate count) Served:

CONGREGATE and/or RESIDENTIAL MEALS Statistical Sections*
A. Number of People (head count) Served:
B. Number of Meals (plate count) Served:

* federal and state funded food may NOT be used by these agencies

Congregate or Residential Meals:
Primary service is not food distribution; but meals are included as part of the services provided, including Residential Treatment Facilities, Child or Adult Day Care, Senior Citizen Center, Group Home, Youth Program, Summer Camp, etc.

Comments:
Thanks for All You Do!

Mail To: The Foodbank, 427 Washington Street, Dayton, Ohio 45402

Fax To: 937.461.3828 Or Call: Rachell Fails at 937.461.0265 x 18

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