FNS-152 Monthly Distribution of Donated Food to Family Units

Attachment 14- FNS 152 Monthly Distribution of Donated Foods to Family Units
FORM APPROVED OMB NO.
0584-0594 Expiration Date:xx/xx/20xx
U.S. DEPARTMENT OF AGRICULTURE
FOOD AND NUTRITION SERVICE

Public reporting burden for this collection of information is estimated to average 2.5 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 (0584-0594), Alexandria, VA 22302. Do not return the completed form to this
address.

MONTHLY DISTRIBUTION OF DONATED
FOODS TO FAMILY UNITS
1. HOUSEHOLDS CERTIFIED

3. NUMBER OF PARTICIPANTS

2. HOUSEHOLDS PARTICIPATING

4. STATE

COMMODITY

7. REPORT MONTH

9. RECEIPTS
REPORTING
UNIT

CODE

AMOUNT
ON HAND
FIRST OF
MONTH

AMOUNT
RECEIVED

(9a)

(9b)

10. WITHDRAWALS

TOTAL
AMOUNT
AMOUNT
AVAILABLE
RE-DONATED
DURING MONTH
IN
(9a) + (9b) + (9c)
(9c)

6. DA CODE

(9d)

11. INVENTORY

AMOUNT
ISSUED

AMOUT
RE-DONATED
OUT

AMOUNT
ON HAND
FIRST OF
MONTH

FOOD
LOSS

(10a)

(10b)

(10c)

(10d)

TOTAL
WITHDRAWALS
(10a) + (10b)
+ (10c) + (10d)
(10e)

BOOK
INVENTORY
END OF MONTH
(9d) - (10e)
(11a)

PHYSICAL
INVENTORY
END OF MONTH
(11b)

ADJUSTMENTS
POSITIVE/
NEGATIVE
(11a) +/- (11b)

LINE NO.

LINE NO.

8. USDA COMMODITY

5. NAME OF SDA/ITO

(11c)

1

BEANS GREEN 30

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

A098

#300 can

5

6

CORN KERNEL 300

A119

#300 can

6

7

CORN CREAM

A120

#303 can

7

8

CORN KERNEL

A121

#303 can

8

9

CORN CREAM 300

A122

#300 can

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

I certify that this report is true and correct to the best of my
knowledge and belief.

16

X

12. SIGNATURE OF APPROVING OFFICIAL

13. TITLE

14. DATE

REMARKS

FORM FNS-152 (07/08) Previous editions obsolete
Electronic Form Version Designed in Adobe 8.1 Version

SBU

Page 1

SDA/ITO

DA CODE

COMMODITY

CODE

9. RECEIPTS
REPORTING
UNIT

AMOUNT
ON HAND
FIRST OF
MONTH

AMOUNT
RECEIVED

(9a)

(9b)

10. WITHDRAWALS

TOTAL
AMOUNT
AMOUNT
AVAILABLE
RE-DONATED
DURING MONTH
IN
(9a) + (9b) + (9c)
(9c)

(9d)

11. INVENTORY

AMOUNT
ISSUED

AMOUT
RE-DONATED
OUT

AMOUNT
ON HAND
FIRST OF
MONTH

FOOD
LOSS

(10a)

(10b)

(10c)

(10d)

TOTAL
WITHDRAWALS
(10a) + (10b)
+ (10c) + (10d)
(10e)

BOOK
INVENTORY
END OF MONTH
(9d) - (10e)
(11a)

PHYSICAL
INVENTORY
END OF MONTH
(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

22
23 SWT POTATOES 303 A221

24#303 can

23

24 SWT POTATOES 300 A223

24#300 can

24

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

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

36 ORANGE J

A300

12/46 oz

36

38 APPLESAUCE 303

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

30

30

37

37

43
FORM FNS-152 (07/08) Previous editions obsolete

43
Page 2

SDA/ITO

DA CODE

COMMODITY

CODE

9. RECEIPTS
REPORTING
UNIT

AMOUNT
ON HAND
FIRST OF
MONTH

AMOUNT
RECEIVED

(9a)

(9b)

10. WITHDRAWALS

TOTAL
AMOUNT
AMOUNT
AVAILABLE
RE-DONATED
DURING MONTH
IN
(9a) + (9b) + (9c)
(9c)

(9d)

11. INVENTORY

AMOUNT
ISSUED

AMOUT
RE-DONATED
OUT

AMOUNT
ON HAND
FIRST OF
MONTH

FOOD
LOSS

(10a)

(10b)

(10c)

(10d)

TOTAL
WITHDRAWALS
(10a) + (10b)
+ (10c) + (10d)
(10e)

BOOK
INVENTORY
END OF MONTH
(9d) - (10e)
(11a)

PHYSICAL
INVENTORY
END OF MONTH
(11b)

ADJUSTMENTS
POSITIVE/
NEGATIVE
(11a) +/- (11b)

LINE NO.

LINE NO.

8. USDA COMMODITY

REPORT MONTH

(11c)

44

44
45 PEARS 300

A437

24#300 can

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

49

49
50 PRUNES 1
52 RAISINS 48

50
51

51

52
53

53

54

54
55 CARROTS 5

F111

10/5 lb.

55

56 CARROTS 1

F113

48/1 lb.

56

57 ONIONS 3

F120

16/3 lb.

57

58 POTATOES RUS BIN 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 TURIPS 3

F171

16/3 lb.

62

63 APPLES FRESH

F511

8/5 lb.

63

64 GRAPEFRUIT 5

F521

8/5 lb.

64

65 ORANGE FRESH

F530

8/5 lb.

65
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

24/24 oz.

FORM FNS-152 (07/08) Previous editions obsolete

70
Page 3

SDA/ITO

DA CODE

COMMODITY

CODE

9. RECEIPTS
REPORTING
UNIT

AMOUNT
ON HAND
FIRST OF
MONTH

AMOUNT
RECEIVED

(9a)

(9b)

10. WITHDRAWALS

TOTAL
AMOUNT
AMOUNT
AVAILABLE
RE-DONATED
DURING MONTH
IN
(9a) + (9b) + (9c)
(9c)

(9d)

11. INVENTORY

AMOUNT
ISSUED

AMOUT
RE-DONATED
OUT

AMOUNT
ON HAND
FIRST OF
MONTH

FOOD
LOSS

(10a)

(10b)

(10c)

(10d)

TOTAL
WITHDRAWALS
(10a) + (10b)
+ (10c) + (10d)
(10e)

BOOK
INVENTORY
END OF MONTH
(9d) - (10e)
(11a)

PHYSICAL
INVENTORY
END OF MONTH
(11b)

ADJUSTMENTS
POSITIVE/
NEGATIVE
(11a) +/- (11b)

LINE NO.

LINE NO.

8. USDA COMMODITY

REPORT MONTH

(11c)

71 STEW 24/15

A589

24/15 oz.

71

72 BEEF 1

A598

36/#1

72

73 BEEF NJ

A610

24/29 oz.

73

74 LUNCHMEAT P 24

A617

24/30 oz.

74

75 PORK NJ

A630

24/29 oz.

75

76 TUNA 12.5

A640

24/12.5 oz.

76

77 TUNA 12.25

A741

24/12.25 oz.

77

78 SALMON PINK

A800

48/14.75 oz.

78

79 SALMON 24

A803

24/14.75 oz.

79
80

80
81 BEANS DK R KIDNEY A906

12/#2

81

82 BEANS BLKEYE 2

A910

12/#2

82

83 BEANS B LIMA 2

A912

12/#2

83

84 BEANS PINTO

A914

12/#2

84

85 BEANS R KIDNEY 2 A915

12/#2

85

86 BEANS Grt NORTH 2 A917

12/#2

86

87 BEANS NAVY PEA 2 A918

12/#2

87

88 BEANS LT KIDNEY 2 A920

12/#2

88

89 PEAS SPLIT 2

A922

12/#2

89

91 BUTTER 36

B050

36/1 lb.

91

92 CHEESE 30

B060

6/5 lb.

92

94 EVAP 12

B081

48/12 fl oz.

94

95 INSTAT 24

B090

6/4 lb.

95

96 EVAP 24

B117

24/12 fl oz.

96

97 CORNMEAL 5 DEG

B137

10/5 lb.

90

90

93

93

FORM FNS-152 (07/08) Previous editions obsolete

97
Page 4

SDA/ITO

DA CODE

COMMODITY

CODE

9. RECEIPTS
REPORTING
UNIT

AMOUNT
ON HAND
FIRST OF
MONTH

AMOUNT
RECEIVED

(9a)

(9b)

10. WITHDRAWALS

TOTAL
AMOUNT
AMOUNT
AVAILABLE
RE-DONATED
DURING MONTH
IN
(9a) + (9b) + (9c)
(9c)

(9d)

11. INVENTORY

AMOUNT
ISSUED

AMOUT
RE-DONATED
OUT

AMOUNT
ON HAND
FIRST OF
MONTH

FOOD
LOSS

(10a)

(10b)

(10c)

(10d)

TOTAL
WITHDRAWALS
(10a) + (10b)
+ (10c) + (10d)
(10e)

BOOK
INVENTORY
END OF MONTH
(9d) - (10e)
(11a)

PHYSICAL
INVENTORY
END OF MONTH
(11b)

ADJUSTMENTS
POSITIVE/
NEGATIVE
(11a) +/- (11b)

LINE NO.

LINE NO.

8. USDA COMMODITY

REPORT MONTH

(11c)

98

98 CORNMEAL 8/5 DEG B138

8/5 lb.

99 CORNMEAL 10 DEG B141

5/10 lb.

99

100 CORNMEAL 40 DEG B142

4/10 lb.

100

101 FORMULA PWD 14.1 B158

24/14 oz.

101
102

102
103 FARINA

B160

24/14 oz.

103
104

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

B163

12/13 fl oz.

107

108 FORMULA 12

B164

12/13 fl oz.

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.

111

112 FORMULA PWDR 6

B168

6/1 lb.

112

113 FORM SOY PWDR 6 B169

6/1 lb.

113
114

114
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

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.

120

121 FLOUR B 10

B230

5/10 lb.

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.

FORM FNS-152 (07/08) Previous editions obsolete

124
Page 5

SDA/ITO

DA CODE

COMMODITY

CODE

9. RECEIPTS
REPORTING
UNIT

AMOUNT
ON HAND
FIRST OF
MONTH

AMOUNT
RECEIVED

(9a)

(9b)

10. WITHDRAWALS

TOTAL
AMOUNT
AMOUNT
AVAILABLE
RE-DONATED
DURING MONTH
IN
(9a) + (9b) + (9c)
(9c)

(9d)

11. INVENTORY

AMOUNT
ISSUED

AMOUT
RE-DONATED
OUT

AMOUNT
ON HAND
FIRST OF
MONTH

FOOD
LOSS

(10a)

(10b)

(10c)

(10d)

TOTAL
WITHDRAWALS
(10a) + (10b)
+ (10c) + (10d)
(10e)

BOOK
INVENTORY
END OF MONTH
(9d) - (10e)
(11a)

PHYSICAL
INVENTORY
END OF MONTH
(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

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

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

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

128

128

131

131
132 HONEY 24

132
133

133

142

142

146

146
147 CER CORN RTE 17.5 B847

14/17.5 oz.

147

148 CEREAL RICE 15

B848

12/15 oz.

148

149 CEREAL CORN 18

B849

12/18 oz.

149

150 CEREAL OATS 16

B851

14/16 oz.

150

151 CEREAL CORN 17.5 B852
FORM FNS-152 (07/08) Previous editions obsolete

12/17.5 oz.

151
Page 6

SDA/ITO

DA CODE

COMMODITY

CODE

9. RECEIPTS
REPORTING
UNIT

AMOUNT
ON HAND
FIRST OF
MONTH

AMOUNT
RECEIVED

(9a)

(9b)

10. WITHDRAWALS

TOTAL
AMOUNT
AMOUNT
AVAILABLE
RE-DONATED
DURING MONTH
IN
(9a) + (9b) + (9c)
(9c)

(9d)

11. INVENTORY

AMOUNT
ISSUED

AMOUT
RE-DONATED
OUT

AMOUNT
ON HAND
FIRST OF
MONTH

FOOD
LOSS

(10a)

(10b)

(10c)

(10d)

TOTAL
WITHDRAWALS
(10a) + (10b)
+ (10c) + (10d)
(10e)

BOOK
INVENTORY
END OF MONTH
(9d) - (10e)
(11a)

PHYSICAL
INVENTORY
END OF MONTH
(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

12/17.5 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
FORM FNS-152 (07/08) Previous editions obsolete

178
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 number 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.

COLUMNS
(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.

(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 t he 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 actual 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 participant s, (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).

(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.

12. Signature. The approving official signs the form here to certify that a physical inventory w as taken
and that the report is true and accurate.
13. Title. Enter the approving official's title.
14. Date. Enter the date the report is signed.