Long Island Cares - The Harry Chapin Food Bank
Agency Monthly Report Form

This form will send an e-mail to the Agency Relations Department.  Please provide the following information and click the SUBMIT button.  If necessary, click the CLEAR button to reset and start over.  Items marked with asterisks (*) are required.  Please, reports are due by the 10th of the following month.  Thank you.

Agency ID *
Agency Name *
Submitted By *
Telephone *
E-Mail Address
   
County *
Month *
Year *
   
Number of Households
(food pantries only)
   
Number of Clients:  
Children
Adults
Seniors
_______
Total Clients
   
Did you receive enough food to adequately feed all those you wanted to serve?
If no, explain why:

Clients income below poverty level = %
Clients income above poverty level = %
                                                            100 %
Amount of your product distribution this month that came from Long Island Cares, Inc. = %

Other comments: