Exhibit L

THE EMERGENCY FOOD ASSISTANCE PROGRAM
PARTICIPATING ORGANIZATION MONTHLY REPORT

(REV. 06/04)

Report Month
And Year:

Name of Distributing
Organization:

Distribution Date(s):

Instructions:

Please complete and sign this report following the end of the month. This report must be submitted to the
appropriate SRS Regional Office no later than ten (10) days following the last day of the report month.
  1.  

Participation Information: Please report the total number of households that received TEFAP food(s) from your
organization during this report month (from 1st calendar day through the last day of the month). This total may be
completed by counting the signatures from all Declaratory Statement/Inventory Control forms (Exhibit E), which
were completed during the report month for each product distributed by the organization.

Total households Served:
  1.  

Inventory Control/Losses: Please report in full case amounts (plus any remaining units) the quantity of products
received.

Product

Total Cases Carried
Over From Last Month

Total Cases
Received

Total
Cases
Distributed

*Total

Cases Lost

*Total Cases on Hand at
End of Report Month

 

 

 

Applesauce

 

 

 

 

 

Canned Pork/Beef

 

 

 

 

 

 

 

Cereal

 

 

 

 

 

 

 

Corn

 

 

 

 

 

 

 

Dry Beans

 

 

 

 

 

 

 

Fruit Juice

 

 

 

 

 

 

 

Green Beans

 

 

 

 

 

 

 

Macaroni

 

 

 

 

 

 

 

Peaches

 

 

 

 

 

 

 

Peanut Butter

 

 

 

 

 

 

 

Pears

 

 

 

 

 

 

 

Peas

 

 

 

 

 

 

 

Potatoes

 

 

 

 

 

 

 

Raisins/Figs/Prunes

 

 

 

 

 

 

 

Rice

 

 

 

 

 

 

 

Refried Beans

 

 

 

 

 

 

 

Salmon

 

 

 

 

 

 

 

Tomatoes

 

 

 

 

 

 

 

Other

 

 

 

 

 

 

 

Other

 

 

 

 

 

 

 

Other

 

 

 

 

 

 

 

Other

 

 

 

 

 

 

 

* If your organization experiences any TEFAP food losses of quantities greater than one case (due to spoilage, theft, or

other reasons), it must be reported to the SRS Regional Office within three working days of the date the loss is discovered. See the Kansas Commodity Distribution Manual, Section 3301.2 for details regarding reporting of losses.

  1.  

 Signature of Authorized Organization Representative

 

Date

This institution is an equal opportunity provider.

8-L