Form FNS-543 NATIONAL HUNGER CLEARINGHOUSE DATABASE FORM

OMB Number 0584-0474
Expiration Date: XX/XX/XXXX

USDA NATIONAL HUNGER CLEARINGHOUSE DATABASE FORM
Facilitating the exchange of information, resources and ideas
among organizations fighting hunger and poverty.

Public reporting burden for this collection of information is estimated to average five minutes 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 burden to: U.S. Department of Agriculture, Food and Nutrition services, Office of Research, Nutrition and
Analysis, Room 1014, (0584-0474), Alexandria, VA 22302. Do not return completed form to this address.
The following information will be added to the USDA National Hunger Clearinghouse Database, an online resource that
provides information about food assistance to the public. Please complete this form and return it to the New York City
Coalition Against Hunger (NYCCAH)
Date:

Organization Name:

Physical Address
City:

State:

Phone:

ext:

Hours of Service:

Zip Code:

Fax:

Email:

Website:

Would you like to receive our monthly e-newsletter?

Yes

No

Organizational Information:
How would you classify your organization? (select all that apply)
Advocacy
Coalition
Direct Services

Education Institution
Emergency Food Provider
Funder

Labor
Religious

What is your organization’s target population? (select all that apply)
Families
Homeless/Unemployed

Immigrants
Senior Citizens

Youth
Other

Where does your organization provide services?
Business
Child Care Center
College University
Community Center
Correction Facility
Detention Facility

Extension Service
Farm
Health Care Facility
Home/Residence
Organizational Offices
Public Housing

Religious institution
School
Senior Citizen Center
Shelter
Soup Kitchen/Food Pantry

Regional
Rural
State

Suburban
Urban

What area does your organization serve?

County
National
Neighborhood

USDA National Hunger Clearinghouse - part of New York City Coalition Against Hunger’s (NYCCAH) Grassroots Action Network
50 Broad Street, Suite 1520
New York, NY 10004
Tel: 212-825-0028
Fax: 212-825-0267
[email protected]
FORM FNS-543 (02-15) Previous Editions Obsolete

SBU

Electronic Form Version Designed in Adobe 10.0 Version
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Agency Services

(Please Mark All That Apply)
Children Service:
After School
Day Care/Childcare
Foster Care/Childcare
Other

Counseling:
Case Management
Crisis Hotline
Domestic Violence
Drugs and Alcohol
Family Support
Individual
Referral Services
Sexual Assault
Other

Food Assistance:
Community Support Agriculture
Farmer’s Markets (EBT)
Food Bank
Food Delivery
Food Pantry
Kids Café
Meals On Wheels
Soup Kitchens
Other

Government Programs:
Child and Adult Care Food Program
CSFP
Earned Income Tax Credit
Farmer’s Market Nutrition Program
FEMA/Disaster Relief
Home Emergency Relief
Senior Farmer’s Market Nutrition Program
SNAP

Health Care:
Health Clinic
Prescription Assistance
Other

Homeless Services
Drop In Center
Emergency Shelter
Halfway Home
Transitional Housing
Other

Jobs:
Career Counseling
Job Placement
Job Readiness
Other

Other Services:
Clothes
Hunger Hotline
Thrift Store

Education:
ESL
Head Start
Nutrition Education
Prison Re-entry Program
Other

Summer Food Service Program
TANF
TEFAP
WIC
Other

Housing:
Appliances/Furniture
Home Repairs
Rent Subsidy
Utilities Assistance
Weatherization
Other

Do you do perform advocacy work? If so, please indicate what kind
Do you provide transportation services?

Yes

No

Do you accept food donations?

Yes

No

Do you provide seasonal services? (i.e. Christmas baskets)

Yes

No

Mission Statement:
***Please write or attach a description of your organization’s background and programs***

Contact Information
The following information is for internal use only. Please provide the contact information for the point of contact for the
New York City Coalition Against Hunger to provide periodic updates of the organizational information above.
First Name:

Middle Initial:

Last Name:
Phone:

Title:
Mobile Phone

Fax:

ext:

Email:

Physical Address
City:

State:

Zip Code:

USDA National Hunger Clearinghouse - part of New York City Coalition Against Hunger’s (NYCCAH) Grassroots Action Network
50 Broad Street, Suite 1520
New York, NY 10004
Tel: 212-825-0028
Fax: 212-825-0267
[email protected]

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