Form FNS-191 Racial/Ethic Group Participation Commodity Supplemental

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U.S. DEPARTMENT OF AGRICULTURE - FOOD AND NUTRITION SERVICE

FORM APPROVED OMB. NO. 0584-0025

RACIAL/ETHNIC GROUP PARTICIPATION
COMMODITY SUPPLEMENTAL FOOD PROGRAM
FNS INSTRUCTION 113-1
2. STATE #

1. STATE
3. REPORTING

L/A #

NO. OF SITES

LOCAL AGENCY NAME
ADDRESS
CITY
STATE

ZIP CODE

TELEPHONE NUMBER
4. REPORTING YEAR:

APRIL

PARTICIPANTS FOR THE MONTH OF APRIL

COLUMN A

TOTAL NUMBER
OF PARTICIPANTS
BY RACE
PARTICIPANTS
WHO MARKED
ONLY ONE
RACE

COLUMN B
NUMBER OF
HISPANIC OR
LATINO
PARTICIPANTS
REPORTED IN
COLUMN A
BY RACE

5. AMERICAN INDIAN OR ALASKA NATIVE
6. ASIAN
7. BLACK OR AFRICAN AMERICAN
8. NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER
9. WHITE

PARTICIPANTS
WHO MARKED
TWO RACES

10. AMERICAN INDIAN OR ALASKA NATIVE AND WHITE
11. ASIAN AND WHITE
12. BLACK OR AFRICAN AMERICAN AND WHITE
13. AMERICAN INDIAN OR ALASKA NATIVE AND BLACK
OR AFRICAN AMERICAN
14. BALANCE REPORTING MORE THAN ONE RACE
15. TOTAL (ADD ITEMS 5 THRU 14)

16. REMARKS

DATE

TITLE

FORM FNS-191 (12/08) Previous Editions are Obsolete
Electronic Form Version Designed in Adobe 8.1 Version

SIGNATURE

SBU

No further monies or other benefits may be paid out under this program
unless this report is completed and filed in accordance with Title VI of
the Civil Rights Act of 1964 and USDA implementing regulations.

INSTRUCTIONS

This report will be prepared annually covering the month of April.
LOCAL AGENCIES - Must submit the data to the State agency by the due date established by the State.
STATE AGENCIES - Must determine that the data has been received from all local agencies. The data must be submitted
to the appropriate FNS Regional Office by the 31st of July.
FNS REGIONAL OFFICES - Must determine that the data has been received from all State and local agencies. The FNS
Regional Office must ensure that all data is posted into the Food Programs Reporting System database by the 19th of
September.
Item 1. Self-explanatory.
Item 2. For the State agency, enter the seven-digit State agency code. For the local agency, enter the 10-digit
identification number assigned by FNS. New local agencies must obtain an identification number from FNS. Enter the
number (001 or more) of sites under each local agency's supervision.
Items 3, 4 and 16. Self-explanatory.
Items 5-15. Report for each racial group the number of participants who received program commodities in April. For
purposes of this form, "Hispanic or Latino" is an ethnic group, not a race. In Column A, report the total number of
participants by race, including individuals of Hispanic or Latino origin. In Column B, report only participants of Hispanic or
Latino origin by race. The form is requesting separate counts for participants who chose only one race and those who
chose more than one race.
For item 14, report the total number of participants who chose racial combinations that are not included in items 10
through 13.

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 for reviewing instructions, searching existing data sources, gathering and maintaining the
data needed, and completing and reviewing the collection of information.

FORM FNS-191 (12/08) Previous Editions are Obsolete