Form FNS-543 National Hunger Clearinghouse Database Form

USDA

iliiiiillllllll

0MB Number 0584-0474
Expiration Date: XX/XX/XX.XX

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

This information is being collected to assist the Food and Nutrition Service in collecting, developing, and distribute information and resources to
help build the capacity of emergency food providers to address the immediate needs of struggling families and individuals. This is a voluntary
collection and FNS will use the information to fight hunger and improve nutrition by increasing participation in the FNS nutrition programs through
the development, coordination, and evaluation of strategic initiatives, partnerships, and outreach activities. This collection does not request any
personally identifiable information under the Privacy Act of 1974. According to the Paperwork Reduction Act of 1995, an agency may not conduct
or sponsor, and a person is not 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 0584-0474. The time required to complete this information collection is estimated to average
[0.0833] hours per response (5 minutes), including the time for reviewing instructions, searching existing data sources, gathering and maintaining
the data needed, and completing and reviewing the collection of information. 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 Service, Office
of Policy Support, 1320 Braddock Place, 5th Floor, Alexandria, VA 22306 ATTN: PRA (0584-0474). Do not return the 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 Hunger Free America.

Organization Name:

Date:

Physical Address: ------------ ------------------------City: _____________ Sta te : _____________ Zip Code: ________

-----------------Hours of Service: ------ Website : ----------------------------Phone:

-------

-------

ext: --- Fax:

Would you like to receive our monthly e-newsletter?

D

Yes

D

Email:
No

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

□ Advocacy
□ Coalition
□ Direct Services

Institution
□ Education
D Emergency Food Provider
□ Funder

What is your organization's target population? (select all that apply)

D
D

Families
Homeless/Unemployed

D
D

Immigrants
Senior Citizens

Where does your organization provide services?
Business
□ Child
Center
□ CollegeCareUniversity
□ Community Center
□ Correction Facility

D
D

Detention Facility

D
D

□
□

D
D

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

What area does your organization serve?

□
□
□

County
National
Neighborhood

D
D
D

Regional
Rural
State

□
□

Labor
Religious

□ Youth
□ Other
Religious Institution
□ School
D
Senior Citizen Center
□ Shelter
□
□ Soup Kitchen/Food Pantry

Suburban
□ Urban
□

USDA National Hunger Clearinghouse - Hunger Free America's Grassroots Action Network
50 Broad Street, Suite 1520
New York, NY 10004
Tel: 212-825-0028
Fax: 212-825-0267

HUNGERFREEAMERICA ORG

Form FNS-543 (05-18) Previous Editions Obsolete

SBU

Electronic Form Version Designed in Adobe 10.0 Version