Local Agency Monthly Statistical Report

*For the Month of: *in:

Complete appropriate Statistical Sections. Reports must be submitted to the foodbank no later than the 15th of the month following the month to which the report pertains.

Check here if any new information:

*Name of Agency:	*Address:	*City:
*Zip:	*County:	*Phone:
Fax:	*Email:	* Required

*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	A With Minor Children	B Without Minor Children	CTotals(Column A + B)
1. Number of Households:

2. Number of Seniors Served (age 60+)
3. Number of Adults Served (18-59)
4. Number of Children Served (Birth - 17)
5.Total Number of People Served

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 Section*
A. Number of People (head count) Served:
B. 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.

Comments:

*Federal and State funded food may NOT be used by these agencies

Mail To: West Ohio Food Bank, P.O. Box 1566, 1380 E. Kibby Street, Lima, OH 45802-1566
Fax: 419-222-2232
Or Call: 419-222-7946

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West Ohio Food Bank

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Local Agency Monthly Statistical Report

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