SOUTHEAST MISSOURI FOOD BANK - MONTHLY REPORT FORM
PANTRIES/SOUP KITCHENS/ON-SITE
County:
Agency Name:
City:
For Month:
Agency #:
Street:
Name of Coordinator:
Total number of households receiving TEFAP commodities (total baskets):
Name of Contact:
Zip:
Phone # of Contact:
SEMO FOOD BANK
Total number of individuals aided by TEFAP commodities (baskets X family size):
Total number of people helped during the month (all assistance except TEFAP):
Total number of individuals served in the month that were 55 & over:
Total number of individuals served in the month that were under 18:
Total number of meals served in the month (Soup Kitchens & On-Site):
Please list the number of food baskets (TEFAP ONLY) served in the quarter to the family sizes listed below:
Baskets served
Current hours of operation:
Submit your report online now:
Or you may print this page and fax to:
Southeast Missouri Food Bank
Attn: Anthony Boren
Fax: (573)651-0405
REPORT DUE TO SEMO FOOD BANK BY THE 5TH WORKING DAY OF EVERY MONTH!
Please indicate any program changes, such as new director, contact person, address, phone number, etc.
Date:
Name:
5
4
3
2
1
Size of family
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Baskets served
10+
9
8
7
6
Size of family
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For assistance, please call Anthony at (573)651-0400 or email aboren@feedingamerica.org
