Form FNS-191 Racial/Ethic Group Participation Commodity Supplemental

Form Approved OMB. No. 0584-0025
U.S. DEPARTMENT OF AGRICULTURE - FOOD AND NUTRITION SERVICE

RACIAL/ETHNIC GROUP PARTICIPATION
COMMODITY SUPPLEMENTAL FOOD PROGRAM
FCS INSTRUCTION 113-2
No further monies or other benefits may be paid out under this program unless this report is completed and filed as required by existing regulation.
(Instructions on reverse of last copy.)
1.

STATE

3.

REPORTING

2.

STATE #

L/A#

NO. OF CLINICS

LOCAL AGENCY NAME
ADDRESS
CITY
STATE

ZIP CODE

4. REPORTING YEAR: APRIL
5.

PARTICIPATION BY RACIAL/ETHNIC GROUP
a.

Black, not of Hispanic origin

b.

Hispanic

c.

Asians or Pacific Islander

d.

American Indian or Alaskan Native

e.

White, not of Hispanic origin

f.

TOTALS (See Instructions)

DATE

TELEPHONE

ACTUAL NUMBER OF PARTICIPANTS FOR THE MONTH OF APRIL
(F) TOTAL
(D) ELDERLY
(B) INFANTS
(C) CHILDREN

(A) WOMEN

TITLE

FORM FCS-191 (9-95) Previous editions are obsolete
Electronic Form Version Designed in Adobe 7.0 version

SIGNATURE

SBU

ORIGINAL - FCS REGIONAL OFFICE

INSTRUCTIONS
This report will be prepared annually covering the month of April.
LOCAL AGENCIES: Shall forward the original and one copy to the
State agency by the 7th day of July, retaining the second copy.
STATE AGENCIES: Shall determine that reports have been received
from all local agencies and review all information prior to forwarding the
original copy to the appropriate FCS regional office in time to reach that
office no later than the 31st day of July. The duplicate copy form shall
be retained and used for analysis in monitoring local agencies and
State agency compliance with civil rights requirements.
FCS REGIONAL OFFICES: Shall determine that all local agency
reports have been received from the State agencies and reviewed for
completeness. The regional office shall enter all local agency
information into the National Master database by the 19th day of
September.
Item 1 and 4 - Self Explanatory.

previous year(s) that was assigned by FCS. New local agencies
shall obtain the identification number from the State agency. The
new local agency 3-digit number should be the next unused
consecutive identification number. Enter the number (001 or more)
of clinics under each local agency's supervision.
Item 3 - Enter the name, address and 10-digit telephone number for
the local Agency. For the name and address, enter on letter or
number in each block. Abbreviations are permitted, where
necessary. This will be used as input information for the CSFP
Local Agency Directory.
Item 5a thru 5e - Data should reflect the ACTUAL number of head
of household participants by Racial/Ethnic Catergory who received
commodity supplemental foods during the month of April.
Item 5f - Add columns a through e.

Item 2 - For State agency, enter 4-digit Letter of Credit number. For
local agency, enter the 3-digit identification number used in

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB
control number. The valid OMB control number for this information collection is 0584-0025. The time required to complete this information collection
is estimated to average 2 hours per response, including the time to review instructions, search existing data resources, gathering and maintaining the
data needed, and completing and reviewing the collection of information.

FORM FCS-191 (9-95) Previous editions are obsolete
Electronic Form Version Designed in JetForm 5.01 version