Monthly Report Form

***REMINDER: EFFECTIVE JANUARY 2010, ANY AGENCY THAT NEGLECTS TO SUBMIT A MONTHLY REPORT FOR 3 CONSECUTIVE MONTHS WILL AUTOMATICALLY BE PUT ON HOLD BY UWCFB.***

Name
Account Number
County
Month AND Year of Report
Name of person completing this form
Unduplicated Count of People Served: Gender Male
Unduplicated Count of People Served: Gender Female
Unduplicated Count of People Served: Total People
Unduplicated Count of People Served: Age Under 6
Unduplicated Count of People Served: Age 6 - 18
Unduplicated Count of People Served: Age 19 - 59
Unduplicated Count of People Served: Age 60+
Unduplicated Count of People Served: Age Total
Soup Kitchens Only - Number of Meals Served
NOTE: Totals for gender and age should be equal. If you did not operate your food program or did not use Food Bank this month, please indicate a “0” in the totals columns.
Any Changes in Program? (i.e.: contact information, change in distribution days or storage areas, etc.)
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