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1 DATE: September, 2015 MEMORANDUM TO: FROM: RE: All TEFAP Agencies Pat Williams TEFAP packet TEFAP information for the 4th quarter of 2015, running October through December can be downloaded from our website in its entirety the last week of September. Please make copies of the reporting form to use for each month, and please get your reports in to me by the 15 th of each month. Your Civil Rights poster must be displayed in your pantry. If you do not have one please contact me and I will get one to you. All pantry staff and volunteers need to be aware of Civil Rights requirements and need to have had the Civil Rights Training. You must do this training one (1) time per year. Be sure to fill out the client form in its entirety once per year. Partial addresses are not acceptable. This is required by NCDA. Clients must sign for their TEFAP box/s each time they pick up. Always ask if anything has changed in their household. Client sheets must be stored at your pantry for a time period of FIVE years per NCDA. Freezer/Refrigerator temperatures must also be recorded daily. See the last column of the monthly report for reporting TEFAP ending inventory for the month. You need to report this inventory in individual cans/units, not cases. It is important that we know your ending inventory each month to complete our tracking ability. TEFAP foods are eligible for the client choice program. If you chose to use client choice in your pantry, please advise the clients that they can choose which of the TEFAP items they would like to receive. When reporting clients served, please report only those clients who received TEFAP. TEFAP may be distributed to eligible clients as often as is needed but not more than once per week. NCDA and MANNA recommends that you use up all your last quarter items before ordering from the next quarter. When ordering, please do not order more than you need! The goal is to give out all you have by the end of each quarter. Please follow this guideline. YOU CAN DOWNLOAD THE ENTIRE PACKET FROM OUR WEBSITE. WE WILL BE UPLOADING IT THE LAST WEEK OF SEPTEMBER. IF YOU WOULD LIKE A PACKET MAILED/ ED PLEASE NOTIFY ME BY PHONE OR . Items allocated for this quarter are applesauce, green beans, corn flakes, dried cherries, canned chicken, chicken leg qtrs., corn, cranberry sauce, ham, apple juice, grapefruit juice, macaroni, peanut butter, and canned pork. If you have any questions please contact me at (828) or toll free My is Thank you very much. Pat

2 TEFAP 04a REVISED 9/4/15 MANNA FoodBank TEFAP DISTRIBUTION REPORT REPORT OF COMMODITIES FOR MONTH OF, 2015 AGENCY NAME AGENCY # PHONE # FAX # ADDRESS NAME AND TITLE OF PERSON COMPLETING THIS FORM REPORT DUE BY THE 15 Th OF THE NEXT MONTH *Reporting period runs from the 1 st day of the month to the last day of the month. *Fill in the invoice number and date in the grid below. Report the item/amount received in CASES. Record this amt in units/cans Week 1 Week 2 Week 3 Week 4 Week 5 END OF MONTH-inventory Invoice # Date Invoice # Date Invoice # Date Invoice # Date Invoice # Date PHYSICAL INVENTORY (actual can/bag count) Commodity Amt/Check Commodity Amt/Check Commodity Amt/Check Commodity Amt/Check Commodity Amt/Check COMMODITY Chicken, canned Chicken Leg Qtrs Cranberry Sauce Juice,Grapefrt ENDING INVENTORY IN IND UNITS/CANS **PLEASE RECORD ACTUAL NUMBER OF INDIVIDUALS SERVED NUMBER OF HOUSEHOLDS TOTAL NUMBER OF INDIVIDUALS - TOTAL **RECORD ENDING MONTHLY INVENTORY IN LAST COLUMN **PLEASE RETURN THIS FORM TO THE FOOD BANK NO LATER THAN THE 15 TH OF THE NEW MONTH. IF YOU HAVE ANY QUESTIONS, PLEASE CALL PAT WILLIAMS AT (828)

3 MANNA FOODBANK, ASHEVILLE, N.C. October, November, December, 2015 TEFAP BALANCED DISTRIBUTION RATES Case lot distribution to agencies based on columns (4) (9) below will help assure that families get full variety and amounts based on N.C.D.A. guidelines. Agencies should distribute to families the full range of items the agency has in stock in the unit amounts per item listed in column (3). A balanced box assures you will run out of all products at the same time. Keep in mind that TEFAP foods are eligible for the client choice program. If you chose to use client choice in your pantry, please advise the clients that they can choose which of the TEFAP items they would like to receive. ITEM PACKAGING UNITS PER FAMILY SIZE 1-3 / 4+ ITEM REVISED 8/31/2015 NUMBER OF FAMILIES AGENCY PLANS TO SERVE (1) (2) (3) (4) (5) (6) (7) (8) (9) APPLESAUCE CAN 1 / 2 APPLESAUCE GREEN BEANS CAN 1 / 2 GREEN BEANS CEREAL, CORN 12/18 OZ 1 / 2 CEREAL, CORN FLAKES FLAKES CHERRIES, DRIED 1 / 2 CHERRIES, DRIED CHICKEN CAN 12/15 OZ 1 / 2 CHICKEN CAN CHICKEN LEG QTR 1 / 2 CHICKEN LEG QTR, FRZ CORN CAN 1 / 2 CORN CRANBERRY CAN 1 / 2 CRANBERRY SAUCE SAUCE HAM, FRZ 1 / 2 HAM, FRZ JUICE, APPLE 8/64 OZ 1 / 2 JUICE, APPLE JUICE, 8/64 OZ 1 / 2 JUICE, GRAPEFRUIT GRAPEFRUIT MACARONI PKG 1 / 2 MACARONI PEANUT BUTTER 12/18 OZ 1 / 2 PEANUT BUTTER PORK, CAN 24/24 OZ 1 / 2 PORK, CAN DISTRIBUTE ALL ITEMS FROM LAST QUARTER AT THE RATE OF 1 FOR HOUSEHOLDS OF 1 3 AND 2 FOR HOUSEHOLES OF 4 OR MORE OR MAKE ALL BOXES THE SAME (one item per box). Exception: CRANBERRY JUICE CONCENTRATE IS 2/4. TO BE ABLE TO ORDER 144 YOU MUST BE THE ONLY TEFAP DISTRIBUTION SITE IN YOUR COUNTY. ***IF YOU WANT TO SERVE MORE CLIENTS YOU CAN PREPARE ALL BOXES USING THE 1-3 FAMILY SIZE REGARDLESS AS TO HOW MANY ARE IN THE FAMILY BUT YOU MUST STAY CONSISTANT WITH THIS DISTRIBUTION RATE THROUGH-OUT THE QUARTER. The U.S. Department of Agriculture (USDA) prohibits discrimination against its customers, employees, and applicants for employment on the bases of race, color, national origin, age, disability, sex, gender identity, religion, reprisal, and where applicable, political beliefs, marital status, familial or parental status, sexual orientation, or if all or part of an individual's income is derived from any public assistance program, or protected genetic information in employment or in any program or activity conducted or funded by the Department. (Not all prohibited bases will apply to all programs and/or employment activities.) If you wish to file a Civil Rights program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, found online at or at any USDA office, or call (866) to request the form. You may also write a letter containing all of the information requested in the form. Send your completed complaint form or letter to us by mail at U.S. Department of Agriculture, Director, Office of Adjudication, 1400 Independence Avenue, S.W., Washington, D.C , by fax (202) or at Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) ; or (800) (in Spanish). USDA is an equal opportunity provider and employer.

4 TEFAP Eligibility Form October 1, 2015 September 30, 2016 Name: Address: City: County: Number of People in Household: Foodstamps yes no Effective October 1, 2015 through September 30, 2016 (Household gross income must be at or below for appropriate size household.) HOUSEHOLD SIZE PER YEAR PER MONTH PER WEEK 1 $23,544 $1,962 $453 2 $31,872 $2,656 $613 3 $40,200 $3,350 $773 4 $48,504 $4,042 $933 5 $56,832 $4,736 $1,093 6 $65,160 $5,430 $1,253 7 $73,464 $6,122 $1,413 8 $81,792 $6,816 $1,573 EACH ADDITIONAL FAMILY MEMBER $8,328 $694 $160 The above table shows a yearly gross income for each family size. If your household income is at or below the income listed for the number of people in your household, you are eligible to receive food. A household is defined as a group of people who live together and share money and other resources in order to get food. Please look at the income scale above to determine if your household is eligible for TEFAP. OR If you currently participate in a Food & Nutrition Services Program (i.e. Food Stamps) you are automatically eligible to receive TEFAP and do not need to look at the income scale. Note: The above may be read to persons who are unable to read. People who are unable to sign their name may sign by using an X. Please read the following statement carefully, then sign the form and write in today s date. I understand that any misrepresentation of need, sale, or misuse of the foods I have received is prohibited and could result in a fine, imprisonment, or both. (Sec. 211 E, PL and Sec. 4C, PL as amended.) The section below is only for homebound individuals The following persons are authorized to pick up my food (if applicable): Authorized Representative: Authorized Representative: (Client Signature) (Date) In accordance with Federal law and USDA policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age or disability. To file a complaint of discrimination, write USDA, Director, Office of Adjudication, 1400 Independence Avenue, SW, Washington, DC or call toll free (866) (voice). Individuals who are hearing impaired or have speech disabilities may contact USDA through the Federal Relay Service at (800) : or (800) (Spanish). USDA is an equal opportunity provider and employer.

5 Date Client Signature FNS Yes No Yearly Income Monthly Income Weekly Income If you do not receive FNS Benefits (i.e. food stamps), write in your yearly, monthly, or weekly income. Agency Representative Signature Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) ; or (800) (in Spanish) In accordance with Federal law and USDA policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age or disability. To file a complaint of discrimination, write USDA, Director, Office of Adjudication, 1400 Independence Avenue, SW, Washington, DC or call toll free (866) (voice). Individuals who are hearing impaired or have speech disabilities may contact USDA through the Federal Relay Service at (800) : or (800) (Spanish). USDA is an equal opportunity provider and employer.

6 FORMA DE ELEGIBILIDAD PARA TEFAP Octubre 2015 Septiembre 2016 Nombre: Dirección: Ciudad: Condado: Número de personas en el hogar: Efectivo desde 1 de Octubre 2015 hasta 30 de Septiembre de 2016 (Los ingresos gruesos tienen que estar en o abajo para el tamaño apropiado del hogar.) TAMAÑO DE HOGAR POR AÑO POR MES POR SEMANA 1 $23,544 $1,962 $453 2 $31,872 $2,656 $613 3 $40,200 $3,350 $773 4 $48,504 $4,042 $933 5 $56,832 $4,736 $1,093 6 $65,160 $5,430 $1,253 7 $73,464 $6,122 $1,413 8 $81,792 $6,816 $1,573 CADA MIEMBRO ADICIONAL DE LA FAMILIA $8,328 $694 $160 La tabla abajo muestra los ingresos gruesos anuales para cada tamaño de familia. Si sus ingresos de hogar están en o debajo los ingresos en la tabla para el número de personas en su hogar, usted es elegible para recibir los alimentos. Un hogar es definido como un grupo de personas que viven juntos y comparten dinero y otros recursos a fin de conseguir el alimento. Por favor mire la escala de ingresos abajo para determinar si su hogar es elegible para TEFAP. O Si usted participa en una programa de estampillas de alimentos, usted es automáticamente elegible para recibir TEFAP y no tiene que mirar la escala de ingresos. Nota: Los siguiente puede ser leído a personas que no saben leer. La gente que es incapaz de firmar su nombre puede firmar usando un X. Por favor lea la declaración siguiente con cuidado, luego firme la forma y escriba la fecha de hoy. Entiendo que cualquier falsificación de necesidad, venta, o mal uso de la comida que he recibido es prohibida y podría causar multas, el encarcelamiento, o ambos. (Sec. 211 E, PL y Sec. 4C, PL 93-86, según enmendado.) La siguiente sección es sólo para los individuos recluidos Las siguientes personas están autorizadas a recoger a mi comida: Representante Autorizado: Representante Autorizado: Firma de persona recogiendo alimentos: (Firma de Cliente) (Fecha) El Departamento de Agricultura de los Estados Unidos (por sus siglas en inglés USDA ) prohíbe la discriminación contra sus clientes, empleados y solicitantes de empleo por raza, color, origen nacional, edad, discapacidad, sexo, identidad de género, religión, represalias y, según corresponda, convicciones políticas, estado civil, estado familiar o paternal, orientación sexual, o si los ingresos de una persona provienen en su totalidad o en parte de un programa de asistencia pública, o información genética protegida de empleo o de cualquier programa o actividad realizada o financiada por el Departamento. (No todos los criterios prohibidos se aplicarán a todos los programas y/o actividades laborales). Si desea presentar una queja por discriminación del programa de Derechos Civiles, complete el USDA Program Discrimination Complaint Form (formulario de quejas por discriminación del programa del USDA), que puede encontrar en internet en o en cualquier oficina del USDA, o llame al (866) para solicitar el formulario. También puede escribir una carta con toda la información solicitada en el formulario. Envíenos su formulario de queja completo o carta por correo postal a U.S. Department of Agriculture, Director, Office of Adjudication, 1400 Independence Avenue, S.W., Washington, D.C , por fax al (202) o por correo electrónico a Las personas sordas, con dificultades auditivas, o con discapacidad del habla pueden contactar al USDA por medio del Federal Relay Service (Servicio federal de transmisión) al (800) o (800) (en español). El USDA es un proveedor y empleador que ofrece igualdad de oportunidades.

7 El programma de estampillas de alimentos Por Ano Por Mes Por Semana Agency Representative Signature Fecha Firma Si No Si usted no recibe estampillas de comida, escribir en tu anual, mensual, semanal o ingresos

8 NORTH CAROLINA DEPARTMENT OF AGRICULTURE AND CONSUMER SERVICES FOOD DISTRIBUTION DIVISION PO Box 659 Butner, NC Loss Report for Month of, 2015 (a) (b) (c) (d) Product Pack Units Lost Explain in Detail Cause of Loss (a) Self Explanatory (b) Self Explanatory (c) List the number of blocks, bags, containers, cans or boxes which have been lost due to damage, pilferage, lack of accountability, etc. (d) Explain in detail the cause of the loss, such as damage in shipping, hidden damage, loss through lack of accountability, etc. (Name of Emergency Feeding Organization) (County) (Signature) (Title) (Date) (Please attach this form to the TEFAP-4)

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