Monthly Reporting Forms

About You
Agency Name*
Agency ID Number*
This Report Was Prepared By*
Phone*
Email*
This report reflects activity in the month of:
Month*
Year*
If You Distribute Food

Please fill out this section:
Total Number of People Helped This Month
Total Number of Families Helped This Month
Total People (By Age Group) That Were Given Food:
6 Years Old & Under - DIS
6 Years Old & Under
7-18 Years Old - DIS
7-18 Years Old
19-54 Years Old - DIS
19-54 Years Old
55+ Years Old - DIS
55+ Years Old
Your Total People Served (By Age)
Please ensure this number matches the total number of people helped that you reported above.
Total People (By Race) That Were Given Food:
Black or African American - DIS
Black or African American
Asian - DIS
Asian
Hispanic or Latino - DIS
Hispanic or Latino
White - DIS
White
American Indian or Alaskan Native - DIS
American Indian or Alaskan Native
Native Hawaiian or Pacific Islander - DIS
Native Hawaiian or Pacific Islander
Middle Eastern or North African - DIS
Middle Eastern or North African
Multi-Racial/Ethnic - DIS
Multi-Racial/Ethnic
Client Prefers Not to Disclose - DIS
Client Prefers Not to Disclose
Other - DIS
Other
Your Total People Served (By Race)
Please ensure this number matches the total number of people helped that you reported above.
If You Serve Meals - Residential

Please fill out this section (scroll down for community meals):
TOTAL NUMBER OF MEALS SERVED THIS MONTH
TOTAL NUMBER OF UNDUPLICATED PEOPLE FED THIS MONTH
TOTAL PEOPLE (BY AGE GROUP) THAT WERE GIVEN FOOD:
6 Years Old & Under - RES
6 Years Old & Under
7-18 Years Old - RES
7-18 Years Old
19-54 Years Old - RES
19-54 Years Old
55+ Years Old - RES
55+ Years Old
YOUR TOTAL PEOPLE SERVED (By Age)
Please ensure this number matches the total number of people helped that you reported above.
TOTAL PEOPLE (BY RACE) THAT WERE GIVEN FOOD:
Black or African American - RES
Black or African American
Asian - RES
Asian
Hispanic or Latino - RES
Hispanic or Latino
White - RES
White
American Indian or Alaskan Native - RES
American Indian or Alaskan Native
Native Hawaiian or Pacific Islander - RES
Native Hawaiian or Pacific Islander
Middle Eastern or North African - RES
Middle Eastern or North African
Multi-Racial/Ethnic - RES
Multi-Racial/Ethnic
Client Prefers Not to Disclose - RES
Client Prefers Not to Disclose
Other - RES
Other
YOUR TOTAL PEOPLE SERVED (BY RACE)
Please ensure this number matches the total number of people helped that you reported above.
If You Serve Meals - Community

Please fill out this section:
TOTAL NUMBER OF MEALS SERVED THIS MONTH
NUMBER OF DAYS MEALS WERE SERVED THIS MONTH
TOTAL PEOPLE (BY AGE GROUP) THAT WERE GIVEN FOOD:
6 Years Old & Under - COM
6 Years Old & Under
7-18 Years Old - COM
7-18 Years Old
19-54 Years Old - COM
19-54 Years Old
55+ Years Old - COM
55+ Years Old
Your Total People Served (By Age)
Please ensure this number matches the total number of people helped that you reported above.
Total People (By Race) That Were Given Food:
Black or African American - COM
Black or African American
Asian - COM
Asian
Hispanic or Latino - COM
Hispanic or Latino
White - COM
White
American Indian or Alaskan Native - COM
American Indian or Alaskan Native
Native Hawaiian or Pacific Islander - COM
Native Hawaiian or Pacific Islander
Middle Eastern or North African - COM
Middle Eastern or North African
Multi-Racial/Ethnic - COM
Multi-Racial/Ethnic
Client Prefers Not to Disclose - COM
Client Prefers Not to Disclose
Other - COM
Other
Your Total People Served (By Race)
Please ensure this number matches the total number of people helped that you reported above.

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Monthly Reporting Forms

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If You Serve Meals - Residential

If You Serve Meals - Community

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