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HRP-1012B FORNA (12-15)

ARIZONA DEPARTMENT OF ECONOMIC SECURITY

Division of Benefits and Medical Eligibility (DBME)

Coordinated Hunger Relief Program

THE EMERGENCY FOOD ASSISTANCE PROGRAM (TEFAP)

FOOD DISTRIBUTION MONTHLY STATISTICAL REPORT/ INSTRUCTIONS AND DEFINITIONS

Instructions and Definitions for the:

Food Distribution Monthly Statistical Report (HRP-1012A)- Excel Spreadsheet. All blanks must be filled-in.

Sub-totals and totals have formulas to automatically total columns.

Reporter: Person’s name who is completing the report

Contract Number: DES contract number indicated on the Award Notice

Food Bank: Food Bank’s name

Month and Year: Reporting period (entered by the food bank)

Sec. I: RECEIPTS - Report how many pounds were received for the following categories:

A. Donated LBS.: Food or non-food product donated from any source

B. Purchased LBS.: Food or non-food product from any source except federal commodities

C. Fed. Comm. LBS.: Food only (USDA commodities)

Column Subtotals: Automatically calculates

Product Categories & Definitions

Salvage: Product that is damaged either at the warehouse or retail level; received directly or indirectly from a reclamation

center; may be food or non-food product

Prepared Foods: Products from such sources as restaurants, delis, caterers, and food service institutions

Produce: ALL Fresh, perishable fruits / vegetables from any source

Food Drives: All products from food drives (e.g., Mail Carriers, Boy Scouts)

Retail/Wholesale: All products (except produce) from a retail or wholesale entity

State Funds: Food only

Miscellaneous / Other: Any product that does not fit the other categories or product transferred from one food bank to

another food bank (e.g., blankets from U.S. Department of Defense)

USDA Commodities: Ordered and bonus product; food only

CSFP / Food Plus: Food only

Other: Food Only

SUBTOTALS: Automatically calculates

From Other Food Banks: Of the poundage reported (donated, purchased or commodities) how much came through other

food banks and not directly from vendor or donor.

TOTAL NET RECEIPTS: Automatically calculates (subtracts amount received from other food banks)

Sec. II: AGENCY DISTRIBUTION LBS. (Counties)

A. County: All non-profit organizations that have agreements with the reporting food bank to act as a distribution point

for food products, and provide food to low-income people and are monitored by your food bank.

Examples include, but are not limited to, SDO’s, soup kitchens, small food banks and pantries, homeless and domestic

violence shelters, etc.

This does NOT include distribution to regional food bank warehouses or to the Arizona Gleaning Project.

B. Total Pounds

C. Receiving Agencies: Actual number of agencies that received food during the reporting period and are monitored by

your food bank

D. Active Agencies: Number of agencies with current agreements on file that you have monitoring responsibility

TOTALS: Automatically calculates

See page 3 for USDA/EOE/ADA/LEP/GINA disclosures

Instructions For Form Hrp-1012b Forna - The Emergency Food Assistance Program (Tefap) Food Distribution Monthly Statistical Report/instructions And Definitions

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