Form FNS-52 Food Requisition

OMB FORM APPROVED NO. 0584-0293
U.S. DEPARTMENT OF AGRICULTURE

STATE

NAME OF DISTRIBUTING AGENCY

CHECK ONE ("x")

TYPE OF ACTION

FOOD AND NUTRITION SERVICE

FOOD REQUISITION

UNITS

ADD

POUNDS

CHANGE
CANCEL

SEE INSTRUCTIONS ON REVERSE
1. COMMODITY (SHORT TITLE) (20)

8.
DELIVERY
ORDER
NO.
(4)

9.
ALLOCATION
NO.
(5)

10 ENDING
SHIPPING/
DELIVERY
DATE
(6)

2. D/A CODE (3) 3. DELIVERY
YEAR (ALPHA)
(1)

4. FISCAL YEAR
OF PURCHASE
(2)

11. PLANNED PROGRAM USAGE BY OUTLET, ADJ CODE & QUANTITY
FIRST LINE: SHOWS OUTLET(S) (4) AND ADJUSTMENT CODE(S) (1)
SECOND LINE: SHOWS QUANTITY FOR EACH OUTLET (7)
OUTLET 1

OUTLET 2

OUTLET 3

OUTLET 4

5. SECTION OF PUBLIC
LAW (3)

FOR FNS USE ONLY
7. STAMP DATE (6)

6. REQUISITION NO. (3)

13.

12.
TOTAL
QUANTITY
(8)

14. DESTINATION
REDO
CODE
(1)

ENTITY CODE
(5)

C/D
(1)

CITY
(16)

The undersigned, being duly authorized to request foods for and on behalf of the agency named above, does hereby certify that local preferences and inventories have been
considered prior to submitting this food request, agrees to accept the food shown hereon upon delivery at destination(s) indicated, and to distribute the entire quantity in
accordance with instructions of the Food and Nutrition Service. The signing of the "Distributing Agency Consignee Receipt" on Form KC-269A by the undersigned or his
designee shall constitute acceptance of the food for and on behalf of the Agency.
15. DISTRIBUTING AGENCY CERTIFICATION
A. DATE

B. SIGNATURE

FORM FNS-52 (9-98) Previous editions obsolete.

C. TITLE

16. FOOD & NUTRITION SERVICE APPROVAL
A. DATE

B. SIGNATURE

C. TITLE

Electronic Form Version Designed in JetForm 5.01 Version

INSTRUCTIONS
ITEMS
STATE - Enter the name of the State in which the

order for any reason other than a destination change after it has
been processed by the Kansas City FSA Commodity Office (KCCO),
the order number shall not be reused; if replacement is necessary,
use a new order number.

Distributing

Agency is located.
DISTRIBUTING AGENCY - Enter the name of the Distributing
Agency
UNITS OR POUNDS - Place an "X" in the applicable box.

9.

ALLOCATION NUMBER - Enter the allocation number provided by
the FNS Regional Office.

10. ENDING SHIPPING/DELIVERY DATE - The final day of the shipping/
delivery period is required. States may show entire requested
shipping/delivery period if desired.

TYPE OF ACTION - Place an "X" in the applicable box.
The numbered blocks will be keyed by FNS Regional Office,
as outlined below.

The numbers appearing in parentheses

after the block title show the maximum number of characters
that may be keyed.

11. PLANNED PROGRAM USAGE BY OUTLET, ADJUSTMENT CODE
AND QUANTITIY - Enter approved codes for planned program
usage as provided by FNS Regional Office. Enter the number of
Units or Pounds requested for each outlet. The total of the outlet
quantities must equal the quantity shown in the TOTAL QUANTITY
column (Block 12). Each planned usage outlet may have one
approved adjustment code, if needed.
12. TOTAL QUANTITY - Total quantitiy must equal the sum of the
quantities shown in the Quantity columns in Block 11.

BLOCK
1.

COMMODITY - Enter the short title as provided by the FNS
Regional Office. (This must be identical to the short title
given in the FNS commodity file.)

2.

D/A/ CODE - Enter the three digit code number of the
Distributing Agency.

3.

DELIVERY YEAR - Enter the alphabetical designation,
provided by FNS Regional Office, for delivery year in which
shipment is to be made, regardless of outlet. For example,
all orders requested for shipment between 7/1/82 and
6/30/83 should have a delivery year code D, for all outlets.

4.

FISCAL YEAR OF PURCHASE - Enter the fiscal year during
which the commodity will be purchased. This information is
provided in allocations for Group A foods and for Group B
foods through a separate coding sheet available from FNS.

5.

SECTION OF PUBLIC LAW - Enter the section of the public
law as advised by the FNS Regional Office.

6.

REQUISITION NUMBER - Leave blank.
use only.

7.

STAMP DATE - Leave blank.

8.

DELIVERY YEAR - Order number assigned by the Distributing
Agency should be expressed in three digits, beginning with
001 for each food unless instructed differently by FNS Regional
Office. If a destination change is necessary to the original
order, the original order must be cancelled and the changed
order would carry the original order number plus an alphabetical
suffix, A, B, or C. suffixes D, E, etc. are used for other types of
delivery order changes, such as when it is necessary to split one
delivery order into two or more. If it is necessary to cancel an

13. REDONATION CODE - If commodity is to be redonated at USDA
expense, as approved by the FNS Regional Office, enter "R", if
redonation is for information only, enter "S".
14. DESTINATION - (Entity Code, Check Digit Code and City). Entity
and check digit codes provided by KCFO for each given destination
must be used. If the city name is less than 7 digits, the State 2letter code must also be shown. If it is necessary to change the
destination for an order already submitted to KCFO, please follow
the instructions for Block 8, Delivery Order Number.

REMARKS - For use by the Distributing Agency or the FNS
Regional Office. remarks will be key entered at the FNS Regional
Office using established codes for standard remarks, combined
code and message, or free from message. Remarks should be
written or typed on the form on the appropriate order number
line. Established remarks codes are available through FNS
Regional Office.

This space for FNS
DISTRIBUTION

This space for FNS use only.
1. The Distributing Agency shall retain the pink copy and forward the
original and other copies (with carbon inserts) to the FNS Regional
Office. If any remarks are given, the last remarks page may also
be kept by the Distributing Agency as a record.
2 After approval by the FNS Regional Office, a buff copy shall be
returned to the Distributing Agency.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of
information unless it displays a valid OMB control number. The valid OMB control number for this information
collection is 0584-0293. The time required to complete this collection is estimated to average 2 hours per
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complete and review the information.