Agency Monthly Data Reporting Form

For Kentucky & Indiana Only

Reports are due by the 15th of the month following the month to which the report pertains.

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This Report is for the month of: Select One January February March April May June July August September October November December , year:

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Name of Agency: Agency Account Number:

Street Address: City: State: Select One OH KY IN Zip:

Please Choose the County In Which Your Agency Resides:

County (Kentucky): Select One Boone Bracken Campbell Gallatin Grant Kenton Mason Owen Pendelton County (Indiana): Select One Dearborn Ohio Switzerland

Area Code: Phone: FAX:

Email:

Name of Person Completing This Form:

Please Complete the Appropriate Data Section(s).

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 Data Section

A) Total Number of Households Served:

B) Total Number of Seniors Served (60 years & Older):

C) Total Number of Adults Served (18-59 years):

D) Total Number of Children Served (0-17 years):

Total Number of People Served (B + C + D):

Meal Site: Provides meals to people in need.

MEAL SITE and/or SHELTER Data Section

Number of People (head count) Served:

Number of Meals (plate count) Served:

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.

CONGREGATE and/or RESIDENTIAL MEALS Data Section

Number of People (head count) Served:

Number of Meals (plate count) Served:

SUPPLEMENTAL Data Section

Number of People Served:

Comments: None.

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If you are having difficulties with this form, click here to send an email to the Freestore Foodbank.

OR

Call: (513)-482-4510

Thanks for All You Do!