Form FNS-53 Multi-Food Requisition

FORM APPROVED OMB NO. 0584-0293
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 response, including the time to review
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U.S. DEPARTMENT OF AGRICULTURE
MULTI-FOOD REQUISITION

QUARTER

STATE OR ITD

DISTRIBUTING AGENCY

AVERAGE PARTICIPATION

ADD

(SEE INSTRUCTIONS ON REVERSE)

1 D/A CODE

2 DELIVERY
YEAR

3 F/R D/O NO.

CHANGE
4 OUTLET 5 ENTITY CODE 6 CITY
11 EST.
COST
PER LB.

9 COMMODITY
CODE

10 COMMODITY
DESCRIPTION
(USE SHORT TITLE)

A060

BEANS GREEN 303

24/303

23.40
24.00

PACK
TYPE

A090

BEANS VEG 300

24/300

CARROTS

24/303

24.00

A120

CORN CREAM

24/303

24.00

A121
A135

CORN KERNEL
LENTILS

24/303

24.00

12/2

24.00

A145

PEAS 303

24/303

24.00

A163

PUMPKIN

24/303

24.00

A166

SPINACH

22.50

A169
A196

POTATOES 303
POTATOES DEHY 12

24/303
24/303
12/1

12.00

A221

SWEET POTATOES 303

24/303

24.00

A244

TOMATO SAUCE 300

24/300

22.50

A248

TOMATOES 303

24/303

24.00

A251

SYRUP P

12/24

25.85

A280

GRAPEFRUIT J

12/46

37.00

APPLE J

12/46

37.50

A285

GRAPE J

12/46

38.00

SIGNATURE

FNS-53 (5/00) Previous editions obsolete
Electronic Form Version Designed in JetForm 5.1 version

14 TOT. NET
WEIGHT
(LBS.)

8 REMARKS
15 TOTAL
VALUE
($)

16 ADJ
CODE

17 SECT.
LAW

18 REDI

24.00

A282

DISTRIBUTING AGENCY CERTIFICATION

7 DELIVERY PERIOD

12 NET WT. 13 OTY.
REQ.
PER UNIT
CASES
(CASE)

A095

DATE

DELETE

FOOD AND NUTRITION SERVICE APPROVAL
REGIONAL OFFICE DATE

SIGNATURE

Page 1

D/A CODE
9 COMMODITY
CODE

F/R-D/O NUMBER

DELIVERY YEAR
10 COMMODITY
DESCRIPTION
(USE SHORT TITLE)

11 EST.
COST
PER LB.

PACK
TYPE

12 NET WT. 13 OTY.
REQ.
PER UNIT
CASES
(CASE)

A286

PINEAPPLE

12/46

37.70

A290

TOMATO J
ORANGE J

12/46
12/46

36.50
37.50

APPLESAUCE 303
F COCKTAIL 303
PEACHES CLING 303
PEARS 303

24/303
24/303
24/303

24.00
24.00
24.00

PINEAPPLE 2
PLUMS 303

24/303
24/2
24/303

24.00
30.00
24.00

PRUNES 1
RAISINS 48

24/1
48/1

24.00
48.00

A562

POULTRY CND
CHICKEN CND

43.50
43.50

A570

EGG MIX 6

24/29
24/29
48/6

A587

STEW CND
STEW 24/15

24/24
24/15

36.00

A589
A610

BEEF NJ

24/29

22.50
43.50

A617
A619

LUNCHMEAT P 24
LUNCHMEAT 24
PORK NJ

24/30
24/30
24/29

45.00
45.00
43.50

TUNA 12.5
TUNA 12.25
SALMON PINK

24/12.50 18.75
24/12.25 18.37
48/14.75 44.25

A300
A355
A401
A412
A439
A446
A461
A480
A502
A560

A630
A740
A741
A800

FNS-53 (5/00) Previous editions obsolete
Electronic Form Version Designed in JetForm 5.1 version

DELIVERY PERIOD
14 TOT. NET
WEIGHT
(LBS.)

15 TOTAL
VALUE
($)

16 ADJ
CODE

17 SECT.
LAW

18 REDI

18.00

Page 2

DELIVERY YEAR

D/A CODE
9 COMMODITY
CODE

10 COMMODITY
DESCRIPTION
(USE SHORT TITLE)

11 EST.
COST
PER LB.

PACK
TYPE

12 NET WT. 13 OTY.
REQ.
PER UNIT
CASES
(CASE)

A910

BEANS BLKEYE 2

12/2

24.00

A912

BEANS B LIMA 2

12/2

24.00

A914

BEANS PINTO 2

12/2

24.00

A917

BEANS GRT NORTH 2

12/2

24.00

A918

BEANS NAVY PEA 2

12/2

A920

BEANS LT KIDNEY 2

12/2

24.00
24.00

A922

PEAS SPLIT 2

12/2

24.00

B050

BUTTER 36

36/1

36.00

B060

CHEESE 30

6/5

30.00

B081

EVAP 12

48/12

40.00

B090

INSTANT 24

6/4

24.00

B137

CORNMEAL 5 DEG

10/5

50.00

B141

CORNMEAL 10 DEG

5/10

50.00

B160

FARINA

24/14

21.00

B161

CEREAL INFANT R8

12/8

6.00

B162

FORMULA SOY DRY

6/14

6.25

B163

FORMULA SOY 12

12/13

10.75

B165
B166
B167

FORMULA
FORMULA SOY
FORMULA POWDER
FORMULA POWDER 6

24/13
24/13

21.50

FLOUR AP 5
FLOUR AP 10
FLOUR B 5

10/5
5/10

50.00
50.00

10/5

50.00

B168
B179
B180
B229

12/1
6/1

FNS-53 (5/00) Previous editions obsolete
Electronic Form Version Designed in JetForm 5.1 version

DELIVERY PERIOD

F/R-D/O NUMBER
14 TOT. NET
WEIGHT
(LBS.)

15 TOTAL
VALUE
($)

16 ADJ
CODE

17 SECT.
LAW

18 REDI

21.50
12.00
6.00

Page 3

DELIVERY YEAR

D/A CODE
9 COMMODITY
CODE

10 COMMODITY
DESCRIPTION
(USE SHORT TITLE)

11 EST.
COST
PER LB.

PACK
TYPE

F/R-D/O NUMBER
12 NET WT. 13 OTY.
REQ.
PER UNIT
CASES
(CASE)

B230

FLOUR B 10

5/10

B349

FLOUR WW 5

10/5

50.00

B350

FLOUR WW 10
FLOUR MIX

5/10

50.00

6/5
24/24

30.00

HONEY 24
MACARONI 1

24/1

24.00

B445

OATS 3

12/3

36.00

PB 2

24/2

48.00

B501

ROASTED 12

24/12

18.00

B510

RICE 2

24/2

B570

WHEAT 3

12/3

48.00
36.00

B666

VEG OIL 48

10/5

23.10

B720

SHORT S 3

12/3

36.00

B835

SPAGHETTI 2

12/2

24.00

B850

CEREAL CORN

24/18

B851

CEREAL CORN 16

27.00
14.00

B852
B860
B861

CEREAL CORN 17.5
CEREAL OATS

14/16
12/17.5
24/15

CEREAL OATS 16
CEREAL RICE

12/16
24/13

13.13
22.50
12.00
19.50

CEREAL RICE 12
CEREAL RICE 17.5

12/13
12/17.5

9.75
13.13

CEREAL WHEAT
CEREAL WHEAT 16

24/18
12/16

27.00
12.00

B871

FNS-53 (5/00) Previous editions obsolete
Electronic Form Version Designed in JetForm 5.1 version

15 TOTAL
VALUE
($)

16 ADJ
CODE

17 SECT.
LAW

18 REDI

36.00

B470

B864
B866
B867
B870

14 TOT. NET
WEIGHT
(LBS.)

50.00

B403
B425

B367

DELIVERY PERIOD

Page 4

INSTRUCTIONS
(For State Distributing Agency or Indian Tribal Organization)
ITEM:
QUARTER - Enter the quarter provided by the FNS Regional Office for School Year in
which shipment is to be made. Example: Q1 (for January, February, or March); Q2, Q3,
or Q4.

DISTRIBUTING AGENCY CERTIFICATION - The person who executed
the "Agreement for Distribution" and use of Donated Commodities
(Form FNS-51) on behalf of the Distributing Agency, or his/her
designee, shall sign and date in ink or indelible pencil.

STAFF - Enter the two-letter State Code in which the Distributing Agency is located.
Example: For UTE Mountain Tribe in Colorado you would enter CO.
NAME OF DISTRIBUTING AGENCY - Enter the name of the Distributing Agency.

(For FNS Regional Office)

AVERAGE PARTICIPATION - Enter the average number of participants served by the
program.

BLOCK:

TYPE OF ACTION - Place an "X" in the applicable category. (Delete, Add, or Change).
BLOCK:
1. DA CODE - Enter the three-digit code number of the Distributing Agency.
2. DELIVERY YEAR (ALPHA) - Enter the alphabetical designation provided by the FNS
Regional Office for the School Year in which shipment is made.
3. FOOD REQUISITION/DELIVERY ORDER NUMBER - Use the same number for both
categories. Assign numbers unless advised by the FNS Regional Offices. The
numbers should begin with 501 each school year, continuing numerically through 899.
4. OUTLET - Enter the appropriate outlet as follows: CSFP for Commodity Supplemental
Food Program; FDIR for Food Distribution Program on Indian Reservations.
5. ENTITY CODE - The entity code is provided by the Kansas City Commodity office
(KCCO) for each given destination.
6. CITY - The City should be spelled out in its entirety.
7. DELIVERY PERIOD (NUMERICAL) - Enter the beginning and ending delivery period
desired. First half: 01/15/98 Second half: 01/31/98.
8. REMARKS - For use by the Distribution Agency or the Regional Office. Indicate
(by city) if shipment should be combined. Example: "Combine w/Rochester." Also list
information important for KCCO to receive such as "No deliveries on Friday."
9. COMMODITY CODE - Items are preprinted. If new item, check with FNS Regional
Office for correct code.
10. COMMODITY DESCRIPTION "SHORT TITLE" - Items are preprinted. If new item,
check with FNS Regional Office for correct short title.
11. ESTIMATED COST PER POUND - Optional entry, cost per pound of a commodity.
12. NET WEIGHT PER UNIT (CASE)/Baler - Items are pre-printed.
13. QUANTITY REQESTED - (CASES)/Balers: Enter the number of full cases/balers
requested.
14. TOTAL NET WEIGHT PER ORDER (POUNDS) - Enter net pack weight per order
(pounds). Net pack weight x units requested = Net weight per order. Total weight
per truckload should not exceed 36,000 pounds net weight. Weight must be adjusted
downward when ordering bulky light weights items such as adult cereal.
15. TOTAL VALUE - Optional entry, total net weight x estimated cost equals total
value.
The following categories should be left blank, for FNS Regional Office or FNS
Headquarters to complete:
16. ADJUSTMENT CODE - (Leave Blank)
17. SECTION LAW - (Leave Blank)
18. REDONATION CODE - (Leave Blank)

3. DELIVERY ORDER/FOOD REQUISITION NUMBER - Begin with
501, continuing numerically through 899.
8. REMARKS Optional.
16. ADJUSTMENT CODE - Refer to IT instructions for appropriate
adjustment codes and their use.
17. SECTION LAW - Commodity Supplemental Food Program (CSFP)
- 17 Food Distrubtion Program on Indian Reservations (FDIR) - 4a.
Bonus Commodities - 416 (Verify with FNS Headquarters for an
updated list of bonus commodities and eligible outlets).
18. REDONATION CODE - Refer to IT instructions for appropriate
redonation codes and their use.
FOOD AND NUTRITION SERVICE APPROVAL - The FNS Regional
Office employee who is authorized to approve Food Requistions
will show the appropriate Regional Office (SERO, MPRO, etc.), and
sign and date. This approval by Regional Office indicates that
States or Tribal Inventory levels have been checked out and the
orders have been prepared in accordance with these instructions.
DISTRIBUTION:
1. The Distribution Agency shall retain one copy and forward the
original and other copies with carbon inserts to the FNs Reigonal
Office.
2. After approval for multi-food shipments, the FNS Regional
Office will send one copy with any changes to the Distribution
Agency. The Regional Office will retain the original.