Fns-53 Usda Multi-food Requisition

FORM APPROVED OMB NO. 0584-0293
Expiration Date XX-2009
Public reporting burden for this collection of information is estimated to average 2 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and
maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of
information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for
reducing this burden, to: U.S. Department of Agriculture, Food and Nutrition Services, Office of Research and Analysis (0584-0293), Alexandria, VA 22302. Do not return the completed form to this
address.

U.S. DEPARTMENT OF AGRICULTURE
MULTI-FOOD REQUISITION

QUARTER

STATE OR ITD

DISTRIBUTING AGENCY

AVERAGE PARTICIPATION

DELETE
ADD

(SEE INSTRUCTIONS ON REVERSE)

1 D/A CODE

2 DELIVERY
YEAR

9 COMMODITY
CODE

10 COMMODITY
DESCRIPTION
(USE SHORT TITLE)

A060

CHANGE

3 F/R 4 OUTLET 5 ENTITY CODE
D/O NO.
11 EST.
COST
PER LB.

6 CITY

PACK
TYPE

12 NET WT.
PER UNIT
(CASE)

BEANS GREEN 303

24/303

23.40

A090

BEANS VEG 300

24/300

24.00

A095

CARROTS

24/303

24.00

A120

CORN CREAM

24/303

24.00

A121

CORN KERNEL

24/303

24.00

A135

LENTILS

12/2

24.00

A145

PEAS 303

24/303

24.00

A163

PUMPKIN

24/303

24.00

A166

SPINACH

24/303

22.50

A169

POTATOES 303

24/303

24.00

A196

POTATOES DEHY 12

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

A282

APPLE J

12/46

37.50

A285

GRAPE J

12/46

38.00

7 DELIVERY PERIOD
13 QTY.
REQ.
CASES

DISTRIBUTING AGENCY CERTIFICATION
DATE

SIGNATURE

FNS-53 (07/08) Previous editions obsolete

14 TOT. NET
WEIGHT
(LBS.)

15 TOTAL
VALUE
($)

16 ADJ
CODE

17 SECT LAW

18 REDI

FOOD AND NUTRITION SERVICE APPROVAL
REGIONAL OFFICE

SBU

8 REMARKS

Electronic Form Version Designed in Adobe 8.1 Version

DATE

SIGNATURE

Page 1

D/A/CODE

DELIVERY YEAR

9 COMMODITY
CODE

10 COMMODITY
DESCRIPTION
(USE SHORT TITLE)

A286

11 EST.
COST
PER LB.

F/R - D/O NUMBER
PACK
TYPE

12 NET WT.
PER UNIT
(CASE)

PINEAPPLE

12/46

37.70

A290

TOMATO J

12/46

36.50

A300

ORANGE J

12/46

37.50

A355

APPLESAUCE 303

24/303

24.00

A401

F COCKTAIL 303

24/303

24.00

A412

PEACHES CLING 303

24/303

24.00

A439

PEARS 303

24/303

24.00

A446

PINEAPPLE 2

24/2

30.00

A461

PLUMS 303

24/303

24.00

A480

PRUNES 1

24/1

24.00

A502

RAISINS 48

48/1

48.00

A560

POULTRY CND

24/29

43.50

A562

CHICKEN CND

24/29

43.50

A570

EGG MIX 6

48/6

18.00

A587

STEW CND

24/24

36.00

A589

STEW 24/15

24/15

22.50

A610

BEEF NJ

24/29

43.50

A617

LUNCHMEAT P 24

24/30

45.00

A619

LUNCHMEAT 24

24/30

45.00

A630

PORK NJ

24/29

43.50

A740

TUNA 12.5

24/12.50

18.75

A741

TUNA 12.25

24/12.25

18.37

A800

SALMON PINK

48/14.75

44.25

FNS-53 (07/08) Previous editions obsolete

13 QTY.
REQ.
CASES

DELIVERY PERIOD
14 TOT. NET
WEIGHT
(LBS.)

15 TOTAL
VALUE
($)

16 ADJ
CODE

17 SECT LAW

18 REDI

Page 2

D/A/CODE

DELIVERY YEAR

9 COMMODITY
CODE

10 COMMODITY
DESCRIPTION
(USE SHORT TITLE)

A910

11 EST.
COST
PER LB.

F/R - D/O NUMBER
PACK
TYPE

12 NET WT.
PER UNIT
(CASE)

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

24.00

A920

BEANS LT KIDNEY 2

12/2

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

FORMULA

24/13

21.50

B166

FORMULA SOY

24/13

21.50

B167

FORMULA POWDER

12/1

12.00

B168

FOMULA POWDER 6

6/1

6.00

B179

FLOUR AP 5

10/5

50.00

B180

FLOUR AP 10

5/10

50.00

B229

FLOUR B 5

10/5

50.00

FNS-53 (07/08) Previous editions obsolete

13 QTY.
REQ.
CASES

DELIVERY PERIOD
14 TOT. NET
WEIGHT
(LBS.)

15 TOTAL
VALUE
($)

16 ADJ
CODE

17 SECT LAW

18 REDI

Page 3

D/A/CODE

DELIVERY YEAR

9 COMMODITY
CODE

10 COMMODITY
DESCRIPTION
(USE SHORT TITLE)

B230

11 EST.
COST
PER LB.

F/R - D/O NUMBER
PACK
TYPE

12 NET WT.
PER UNIT
(CASE)

FLOUR B 10

5/10

50.00

B349

FLOUR WW 5

10/5

50.00

B350

FLOUR WW 10

5/10

50.00

B367

FLOUR MIX

6/5

30.00

B403

HONEY 24

24/24

36.00

B425

MACARONI 1

24/1

24.00

B445

OATS 3

12/3

36.00

B470

PB 2

24/2

48.00

B501

ROASTED 12

24/12

18.00

B510

RICE 2

24/2

48.00

B570

WHEAT 3

12/3

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

27.00

B851

CEREAL CORN 16

14/16

14.00

B852

CEREAL CORN 17.5

12/17.5

13.13

B860

CEREAL OATS

24/15

22.50

B861

CEREAL OATS 16

12/16

12.00

B864

CEREAL RICE

24/13

19.50

B866

CEREAL RICE 12

12/13

9.75

B867

CEREAL RICE 17.5

12/17.5

13.13

B870

CEREAL WHEAT

24/18

27.00

B871

CEREAL WHEAT 16

12/16

12.00

FNS-53 (07/08) Previous editions obsolete

13 QTY.
REQ.
CASES

DELIVERY PERIOD
14 TOT. NET
WEIGHT
(LBS.)

15 TOTAL
VALUE
($)

16 ADJ
CODE

17 SECT LAW

18 REDI

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

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.
(For FNS Regional Office)
BLOCK:
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.