Tips for Filling
Out this Form

How to report Regular Service: Each person in each household should be counted once per month.

How to report Extra Service: If you serve the same people more than once this month, total and report their additional visits here. For instance, if a family is served three times this month, count their last two visits in this section.

How to report Pounds and Vouchers: Everything you distribute to a family during your distribution should be reported here, regardless of where it was obtained. This includes food and non-food products and cash or product vouchers redeemable at a store. All food and non-food items should be weighed on a scale, if possible. For vouchers, use the formula: 1 dollar = 1 pound.

How to report First Visits by Individuals: This is the number of people served this month for the first time in this calendar year. For example, if a mother comes for the first time this year in February and she has three children, enter four.

All agencies are required to fill out a monthly Service Statistics Report Form. Reports are due the 10th of the following month (i.e. April's is due by May 10th). If you serve food (regardless of where it is obtained) you must submit a report. If you did not serve any food, a zero report may be submitted.

Monthly Food Pantry & BackPack Stats Form

If you are unsure of how to record your statistics or you have any questions, please call us at 715-835-9415.

Statistics are for the month of:

  

Agency

Contact Name

Contact Phone

Email


Regular Service (1st Visit this Month)

Individuals
(Ages 0-17)

Individuals
(Ages 18-59)

Individuals
(Ages 60+)

Households*

Total Pounds/Vouchers*


Extra Service (2nd+ Visit this Month)

Individuals
(Ages 0-17)

Individuals
(Ages 18-59)

Individuals
(Ages 60+)

Households

Total Pounds/ Vouchers


Total for this Month

Individuals
(Ages 0-17)

Individuals
(Ages 18-59)

Individuals
(Ages 60+)

Households

Total Pounds/Vouchers


First visits by individuals*

*This is the number of people served this month for the first time in this calendar year.

Are the weights exact measurements or estimations?*

 The weights are exact.

 The weights are estimated.


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