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pdfFORM APPROVED OMB NO. 0584-0293
U.S. DEPARTMENT OF AGRICULTURE
FOOD AND NUTRITION SERVICE
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.
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MONTHLY DISTRIBUTION OF DONATED
FOODS TO FAMILY UNITS
1. HOUSEHOLDS CERTIFIED
3. NUMBER OF PARTICIPANTS
2. HOUSEHOLDS PARTICIPATING
4. STATE
LINE NO.
COMMODITY
CODE
REPORTING
UNIT
AMOUNT
ON HAND
FIRST OF
MONTH
AMOUNT
RECEIVED
(9a)
(9b)
6. DA CODE
7. REPORT MONTH
9. RECEIPTS
8. USDA COMMODITY
5. NAME OF SDA/ITO
10. WITHDRAWALS
AMOUNT
REDONATED
IN
(9c)
TOTAL
AMOUNT
AVAILABLE
DURING
MONTH
(9a) + (9b) +
(9c) =
(9d)
AMOUNT
ISSUED
(10a)
AMOUNT
REDONATED
OUT
(10b)
AMOUNT
ON HAND
FIRST OF
MONTH
(10c)
11. INVENTORY
FOOD LOSS
(10d)
TOTAL
WITH
DRAWALS
(10a) + (10b)
(10c) + (10d)
=
(10e)
BOOK
INVENTORY
END OF
MONTH
PHYSICAL
INVENTORY
END OF
MONTH
(9d) - (10e) =
(11a)
(11b)
ADJUSTMENTS
POSITIVE/
NEGATIVE
(11a -/+ 11b) =
(11c)
1 BEANS GREEN 300
A059
#300 can
1
2 BEANS GREEN 303
A060
#303 can
2
3 BEANS VEG/ 300
A090
#300 can
3
4 CARROTS
A095
#303 can
4
5 CARROTS 300
6 CORN KERNEL 300
A098
#300 can
A119
#300 can
5
6
7 CORN CREAM
A120
#303 can
7
8 CORN KERNEL
A121
#303 can
9 CORN CREAM 300
A122
#300 can
8
9
10
10
11
11
12 LENTILS
A135
2# pkg.
12
13 PEAS 300
A144
#300 can
13
14 PEAS 303
A145
#303 can
14
15 PUMPKIN
A163
#303 can
15
16 PUMPKIN 300
A164
#300 can
16
I certify that this report is true and correct to the best of my
knowledge and belief.
12. SIGNATURE OF APPROVING OFFICIAL
13. TITLE
14. DATE
REMARKS
FORM FNS-152 (5-00) Previous editions obsolete
Electronic Form Version Designed in JetForm 5.01 Version
Page 1
SDA/ITO
DA CODE
COMMODITY
CODE
9. RECEIPTS
REPORTING
UNIT
AMOUNT
ON HAND
FIRST OF
MONTH
AMOUNT
RECEIVED
(9a)
(9b)
AMOUNT
REDONATED
IN
(9c)
10. WITHDRAWALS
TOTAL
AMOUNT
AVAILABLE
DURING
MONTH
(9a) + (9b) +
(9c) =
(9d)
AMOUNT
ISSUED
(10a)
AMOUNT
REDONATED
OUT
(10b)
AMOUNT
ON HAND
FIRST OF
MONTH
(10c)
FOOD LOSS
(10d)
11. INVENTORY
TOTAL
WITH
DRAWALS
(10a) + (10b)
(10c) + (10d)
=
(10e)
BOOK
INVENTORY
END OF
MONTH
(9d) - (10e) =
PHYSICAL
INVENTORY
END OF
MONTH
(11a)
(11b)
ADJUSTMENTS
POSITIVE/
NEGATIVE
(11a -/+ 11b) =
LINE NO.
LINE NO.
8. USDA COMMODITY
REPORT MONTH
(11c)
17 SPINACH
A166
24#303 can
17
18 SPINACH 300
A167
24#300 can
18
19 POTATOES 303
A169
24#300-303
19
20 POTATOES SLC 300
A170
24#300 can
20
21 POTATOES DHY 12
A196
12/1 # pkg
21
22
23 SWT POTATOES 303 A221
24#303 can
23
24 SWT POTATOES 300 A223
24#300 can
24
22
25 TOMATOES 300
A240
24#300 can
25
26 TOM SAUCE 300
A244
24#300-303
26
27 TOMATOES 303
A248
24#303 can
27
28 SYRUP P
A251
12/24 oz
28
29 SYRUP P 12/24
A258
12/24 oz
29
30
30
31 GRAPEFRUIT J
A280
12/46 oz
31
32 APPLE J
A282
12/46 oz
32
33 GRAPE J
A285
12/46 oz
33
34 PINEAPPLE J
A286
12/46 oz
34
35 TOMATO J
A290
12/46 oz
35
ORANGE J
A300
12/46 oz
36
36
37
37
A355
24#303 can
38
39 F COCKTAIL 303
A401
24/#303 can
39
40 F COCKTAIL 300
A403
24/#300 can
40
41 PEACHES CLG 300
A411
24/#300 can
41
42 PEACHES CLG 303
A412
24/#303 can
42
38 APPLESAUCE 303
43
FORM FNS-152 (5/00) Previous editions obsolete
43
Electronic Form Version Designed in JetForm 5.01 Version
Page 2
SDA/ITO
DA CODE
COMMODITY
CODE
9. RECEIPTS
REPORTING
UNIT
AMOUNT
ON HAND
FIRST OF
MONTH
(9a)
AMOUNT
RECEIVED
(9b)
AMOUNT
REDONATED
IN
(9c)
10. WITHDRAWALS
TOTAL
AMOUNT
AVAILABLE
DURING
MONTH
(9a) + (9b) +
(9c) =
(9d)
AMOUNT
ISSUED
(10a)
AMOUNT
REDONATED
OUT
(10b)
AMOUNT
ON HAND
FIRST OF
MONTH
(10c)
FOOD LOSS
(10d)
11. INVENTORY
TOTAL
WITH
DRAWALS
(10a) + (10b)
(10c) + (10d)
=
(10e)
BOOK
INVENTORY
END OF
MONTH
PHYSICAL
INVENTORY
END OF
MONTH
(9d) - (10e) =
(11a)
(11b)
ADJUSTMENTS
POSITIVE/
NEGATIVE
(11a -/+ 11b) =
LINE NO.
LINE NO.
8. USDA COMMODITY
REPORT MONTH
(11c)
44
45 PEARS 300
A437
24/#300 can
44
45
46 PEARS 303
A439
24/#303 can
46
47 PINEAPPLE 2
A446
24/#2 can
47
48 PLUMS 303
A461
24/#303 can
48
A480
24/#1 can
A502
48/#1 can
55 CARROTS 5
F111
10/5 lb.
55
56 CARROTS 1
F113
48/1 lb.
57 ONIONS 3
58 POTATOES RUS BIN
F120
16/3 lb.
56
F130
200/5 lb.
58
59 POTATOES RUS 5
F131
8/5 lb.
59
60 POTATOES RED
F140
16/3 lb.
60
61 SQUASH YEL
F151
1/24 lb.
61
62 TURNIPS 3
F171
16/3 lb.
62
63 APPLES FRESH
F511
8/5 lb.
64 GRAPEFRUIT 5
F521
8/5 lb.
63
64
65 ORANGE FRESH
F530
8/5 lb.
65
49
50 PRUNES 1
49
50
51
52 RAISINS 48
51
52
53
53
54
54
57
66
66
67
67
68 CHICKEN CND
A562
24/29 oz.
68
69 EGG MIX 6
A570
48/6 oz.
69
70 STEW CND
A587
24/24oz.
FORM FNS-152 (5/00) Previous editions obsolete
70
Electronic Form Version Designed in JetForm 5.01 Version
Page 3
SDA/ITO
DA CODE
COMMODITY
CODE
9. RECEIPTS
REPORTING
UNIT
AMOUNT
ON HAND
FIRST OF
MONTH
(9a)
AMOUNT
RECEIVED
(9b)
AMOUNT
REDONATED
IN
(9c)
10. WITHDRAWALS
TOTAL
AMOUNT
AVAILABLE
DURING
MONTH
(9a) + (9b) +
(9c) =
(9d)
AMOUNT
ISSUED
(10a)
AMOUNT
REDONATED
OUT
(10b)
AMOUNT
ON HAND
FIRST OF
MONTH
(10c)
FOOD LOSS
(10d)
11. INVENTORY
TOTAL
WITH
DRAWALS
(10a) + (10b)
(10c) + (10d)
=
(10e)
BOOK
INVENTORY
END OF
MONTH
PHYSICAL
INVENTORY
END OF
MONTH
(9d) - (10e) =
(11a)
(11b)
ADJUSTMENTS
POSITIVE/
NEGATIVE
(11a -/+ 11b) =
LINE NO.
LINE NO.
8. USDA COMMODITY
REPORT MONTH
(11c)
71 STEW 24/15
72 BEEF 1
A589
24/15 oz.
A598
36/#1
44
45
73 BEEF NJ
A610
24/29 oz.
46
74 LUNCHMEAT P 24
75 PORK NJ
A617
24/30 oz.
47
A630
24/29 oz.
48
76 TUNA 12.5
A740
24/12.5 oz.
49
77 TUNA 12.25
A741
24/12.25 oz.
50
78 SALMON PINK
A800
48/14.75 oz.
79 SALMON 24
A803
24/14.75 oz.
51
52
53
80
81 BEANS DK R KIDNEY A906
12/#2
54
82 BEANS BLKEYE 2
A910
12/#2
55
83 BEANS B LIMA 2
A912
12/#2
56
84 BEANS PINTO
85 BEANS R KIDNEY 2
A914
12/#2
57
A915
12/#2
58
86 BEANS GRT NORTH 2 A917
12/#2
59
87 BEANS NAVY PEA 2
A918
12/#2
60
88 BEANS LT KIDNEY 2
A920
12/#2
61
89 PEAS SPLIT 2
A922
12/#2
62
91 BUTTER 36
B050
36/1 lb.
63
64
92 CHEESE 30
B060
6/5 lb.
65
90
66
93
94 EVAP 12
B081
48/12 fl oz.
95 INSTANT 24
B090
6/4 lb.
68
96 EVAP 24
B117
24/12 fl oz.
69
97 CORNMEAL 5 DEG
B137
10/5 lb.
FORM FNS-152 (5/00) Previous editions obsolete
67
70
Electronic Form Version Designed in JetForm 5.01 Version
Page 4
SDA/ITO
DA CODE
COMMODITY
CODE
9. RECEIPTS
REPORTING
UNIT
AMOUNT
ON HAND
FIRST OF
MONTH
(9a)
AMOUNT
RECEIVED
(9b)
AMOUNT
REDONATED
IN
(9c)
10. WITHDRAWALS
TOTAL
AMOUNT
AVAILABLE
DURING
MONTH
(9a) + (9b) +
(9c) =
(9d)
AMOUNT
ISSUED
(10a)
AMOUNT
REDONATED
OUT
(10b)
AMOUNT
ON HAND
FIRST OF
MONTH
(10c)
FOOD LOSS
(10d)
11. INVENTORY
TOTAL
WITH
DRAWALS
(10a) + (10b)
(10c) + (10d)
=
(10e)
BOOK
INVENTORY
END OF
MONTH
PHYSICAL
INVENTORY
END OF
MONTH
(9d) - (10e) =
(11a)
(11b)
ADJUSTMENTS
POSITIVE/
NEGATIVE
(11a -/+ 11b) =
LINE NO.
LINE NO.
8. USDA COMMODITY
REPORT MONTH
(11c)
98 CORNMEAL 8/5 DEG
B138
8/5 lb.
98
99 CORNMEAL 10 DEG
B141
5/10 ;lb.
99
100 CORNMEAL 40 DEG
B142
4/10 lb.
100
101 FORMULA PWDR 14.1 B158
102
24/14 oz.
101
103 FARINA
104
B160
24/14 oz.
103
104
105 CEREAL INFANT R8
B161
12/8 oz.
105
106 FORM SOY DRY 6/14 B162
6/14 oz.
106
107 FORMULA SOY 12
108 FORMULA 12
B163
12/13 fl oz.
B164
12/13 fl oz.
107
108
109 FORMULA
B165
24/13 fl oz.
109
110 FORMULA SOY
B166
24/13 fl oz.
110
111 FORMULA POWDER
B167
12/1 lb.
102
112 FORMULA POWDER 6 B168
6/1 lb.
111
112
113 FORM SOY PWDR 6
B169
6/1 lb.
113
115 FLOUR AP 5
B179
10/5 lb.
115
116 FLOUR AP 10
B180
5/10 lb.
116
117 FLOUR AP 10 UNBL
B181
5.10 lb.
117
114
114
118 FLOUR AP 8/5
B182
8/5 lb.
118
119 FLOUR AP 40
B183
4/10 lb.
119
120 FLOUR AP 40 UNBL
B188
4/10 lb.
121 FLOUR B 10
B230
5/10 lb.
120
121
122 FLOUR B 8/5
B232
8/5 lb.
122
123 FLOUR B 40
B233
4/10 lb.
123
124 FLOUR WW 10
B350
5/10 lb.
124
FORM FNS-152 (5/00) Previous editions obsolete
Electronic Form Version Designed in JetForm 5.01 Version
Page 5
SDA/ITO
DA CODE
COMMODITY
CODE
9. RECEIPTS
REPORTING
UNIT
AMOUNT
ON HAND
FIRST OF
MONTH
AMOUNT
RECEIVED
(9a)
(9b)
AMOUNT
REDONATED
IN
(9c)
10. WITHDRAWALS
TOTAL
AMOUNT
AVAILABLE
DURING
MONTH
(9a) + (9b) +
(9c) =
(9d)
AMOUNT
ISSUED
(10a)
AMOUNT
REDONATED
OUT
(10b)
AMOUNT
ON HAND
FIRST OF
MONTH
(10c)
FOOD LOSS
(10d)
11. INVENTORY
TOTAL
WITH
DRAWALS
(10a) + (10b)
(10c) + (10d)
=
(10e)
BOOK
INVENTORY
END OF
MONTH
(9d) - (10e) =
PHYSICAL
INVENTORY
END OF
MONTH
(11a)
(11b)
ADJUSTMENTS
POSITIVE/
NEGATIVE
(11a -/+ 11b) =
LINE NO.
LINE NO.
8. USDA COMMODITY
REPORT MONTH
(11c)
125 FLOUR WW 40
B351
4/10 lb.
125
126 FLOUR MIX
B367
6/5 lb.
126
127 FLOUR MIX LOFAT
B368
6/5 lb.
127
128
128
129 GRITS CW 5
B381
10/5 lb.
129
130 GRITS CW 40
B382
8/5 lb.
130
B403
24/24 oz.
134 MACARONI 1
B425
24/1 lb.
134
135 MAC N CHEESE
B436
12/26 oz.
135
131
131
132 HONEY 24
132
133
133
136 OATS 3
B445
12/3 lb.
136
137 PB 2
B470
24/2 lb.
137
138 PB RDI-FAT 2
B471
24/2 lb.
138
139 CHUNKY RDU-FAT 2 B488
24/2 lb.
139
140 ROASTED 12
B501
24/12 oz.
140
141 RICE 2
B510
24/2 lb.
141
142
142
143 VEG OIL 48
B666
8/48 oz.
143
144 SHORT S
B720
12/3 lb.
144
145 SPAGHETTI 2
B835
12/2 lb.
145
146
146
147 CER CORN RTE 17.5 B847
14/17.5 oz.
147
148 CERAL RICE 15
B848
12/15 oz.
148
149 CERAL CORN 18
B849
12/18 oz.
149
150 CERAL OATS 16
B851
14/16 oz.
150
151 CEREAL CORN 17.5
B852
12/17.5 oz.
151
FORM FNS-152 (5/00) Previous editions obsolete
Electronic Form Version Designed in JetForm 5.01 Version
Page 6
SDA/ITO
DA CODE
COMMODITY
CODE
9. RECEIPTS
REPORTING
UNIT
AMOUNT
ON HAND
FIRST OF
MONTH
(9a)
AMOUNT
RECEIVED
(9b)
AMOUNT
REDONATED
IN
(9c)
11. INVENTORY
10. WITHDRAWALS
TOTAL
AMOUNT
AVAILABLE
DURING
MONTH
(9a) + (9b) +
(9c) =
(9d)
AMOUNT
ISSUED
(10a)
AMOUNT
REDONATED
OUT
(10b)
AMOUNT
ON HAND
FIRST OF
MONTH
(10c)
FOOD LOSS
(10d)
TOTAL
WITH
DRAWALS
(10a) + (10b)
(10c) + (10d)
=
(10e)
BOOK
INVENTORY
END OF
MONTH
PHYSICAL
INVENTORY
END OF
MONTH
(9d) - (10e) =
(11a)
(11b)
ADJUSTMENTS
POSITIVE/
NEGATIVE
(11a -/+ 11b) =
LINE NO.
LINE NO.
8. USDA COMMODITY
REPORT MONTH
(11c)
152 CEREAL OATS 15.5
B854
12/15.5 oz.
152
153 CEREAL OATS
B860
12/15 oz.
153
154 CEREAL OATS 16
B861
12/16 oz.
154
155 CEREAL RICE 12
B866
12/13 oz.
155
156 CEREAL RICE 17.5
B867
12/17.5 oz.
156
157 CER RICE RTE 17.5
B868
14/17.5 oz.
157
158 CEREAL WHEAT 16
B871
12/16 oz.
158
159 CER WHEAT RTE 16 B872
14/16 oz.
159
160
160
161
161
162
162
163
163
164
164
165
165
166
166
167
167
168
168
169
169
170
170
171
171
172
172
173
173
174
174
175
175
176
176
177
177
178
178
FORM FNS-152 (5/00) Previous editions obsolete
Electronic Form Version Designed in JetForm 5.01 Version
Page 7
FORM FNS-152 INSTRUCTIONS
SUBMISSION: Forward the original of this document to the appropriate Food and Nutrition Service (FNS)
office no later than 30 calendar days following the last day of the month being reported. SDAs do not
complete items 1, 2, 3, or Column 10c. SDAs are those facilities which hold FDPIR inventory but do not
issue commodities to program participants.
ITEM
1. Number of Households Certified. Enter the number of households (not individual persons)
which have been certified eligible to receive commodities from this Distribution Center during the report
month.
2. Number of Households Participating. Enter the total lnumber of households (not individual
persons) which actually received commodities from this Distribution Center during the report month.
3. Number of Participants. Enter the total number of persons in households which actually
received commodities from this Distribution Center during the report month.
4. State. Enter the name of the State in which the SDA or ITO is located.
5. Name of State Distributing Agency (SDA) or Indian Tribal Organization (ITO). Enter the
name of the SDA or the reporting ITO acting as the SDA.
6. Distributing Agency Code. Enter the 4 digit SNPIIS code for the reporting SDA or ITO.
7. Report for the Month of. Enter the month and year for which data is reported.
COLLUMNS
(8a) (8b) & (8c) Preprinted.
All commodities being reported must agree with the commodity title and commodity code as
preprinted on the form. If a specific commodity is not preprinted, it must be written in along with the
correct commodity short title, commodity code and reporting unit (e.g., #300 can, 16 oz. box, 2 lb. bag).
Blank spaces are provided for this purpose. For all commodities, report the number of individual units,
such as bags, boxes, cans, foils, etc., not the number of containers in which multiple units are packed.
(9a) Amount on hand first of month. This amount must be the same as the previous month's
"Physical inventory end of month (11b)." Include all foods held in storage by the SDA or reporting ITO.
(9b) Amount received. Indicate in this column the quantity of individual units received in good
condition from USDA during the month.
(9c) Amount redonated in. Indicate the quantity of individual units redonated from another SDA,
program or ITO.
(9d) Total amount available during month. Enter the total of columns: (9a) amount on hand first
of month, (9b) amount received, and (9c) amount redonated out.
(10a) Amount issued. ITOs enter the total number of commodity units actually issued to and
accepted by participants during the report month as specified below. This figure should exclude (1) those
commodities not accepted by the participant at the time of food pick-up, and (2) any commodities returned
to the ITO by participants during the report month. If a participant has refused a commodity at pick-up, it
should not be considered issued. SDAs enter commodity units delivered to ITOs for distribution to program
participants.
(10b) Amount redonated out. When a commodity is redonated to another SDA, program or ITO,
indicate the amount redonated.
(10c) Amount used for nutrition education. When a commodity is used for food demonstrations
or taste testing as part of the SDA's or ITO's nutrition education program, indicate the amount (in units)
used for this purpose.
(10d) Food loss. Provide the appropriate explanation code for all lost food. Enter the number of
commodities that are actualn food losses. These would include foods that: (A) after consignee receipt
were found to have concealed damage; (B) were damaged in the warehouse or during transit from the
State warehouse to the local site; (C) were found to be out of condition or unfit for human consumption;
or (D) were known to have been stolen or lost due to fraud, misuse or embezzlement. Additional details
may be provided in the REMARKS section. (Attach additional pages if necessary.)
(10e) Total withdrawals. Enter the total of columns: (10a) issued to participants, (10b) redonated
out, (10C) used for nutrition program, and (10d) lost.
(11a) Book inventory end of month. Column (9d) minus Column (10e).
(11b) Physical inventory end of month. Report total number of individual units for each commodity
which a physical inventory determines to be in warehouse.
(11c) Inventory Adjustments - Positive/Negative. Column (11a) minus/plus equal Column (11c).
12. Signature. The approving official signs the form heere to certify that a physical inventory
was taken and that the report is true and accurate.
13. Title. Enter the approving official's title.
14. Date. Enter he date the report is signed.
Page 8
File Type | application/pdf |
File Title | JetForm:FNS-152.IFD |
Author | lhibbitts |
File Modified | 2006-08-10 |
File Created | 2006-08-10 |