FNS-101 Participation in Food Programs - By Race

Print

FORM APPROVED OMB NO. 0584-0025
Expiration Date XX/XX/XXXX
U.S. DEPARTMENT OF AGRICULTURE - FOOD AND NUTRITION SERVICE

PARTICIPATION IN FOOD PROGRAMS - BY RACE
FNS Instruction 113-1

1. STATE/ITO:

2. PROGRAM: ("X" one only)

3A. NAME OF PROJECT AREA:

3B. PROJECT AREA CODE:

SNAP
FDPIR
4. NAME & ADDRESS OF REPORTING AGENCY:

5. REPORTING YEAR:
JULY

HOUSEHOLD

6. AMERICAN INDIAN OR ALASKA NATIVE

CONTACTS

7. ASIAN

WHO

8. BLACK OR AFRICAN AMERICAN

MARKED

9. NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER

ONLY ONE

COLUMN A

COLUMN B

TOTAL
NUMBER OF
HOUSEHOLD
CONTACTS
BY RACE

NUMBER OF
HISPANIC
OR LATINO
HOUSEHOLD
CONTACTS
REPORTED
IN COLUMN A
BY RACE

10. WHITE

RACE
HOUSEHOLD

11. AMERICAN INDIAN OR ALASKA NATIVE AND WHITE

CONTACTS

12. ASIAN AND WHITE

WHO

13. BLACK OR AFRICAN AMERICAN AND WHITE

MARKED

14. AMERICAN INDIAN OR ALASKA NATIVE AND BLACK OR
AFRICAN AMERICAN

TWO RACES

15. BALANCE REPORTING MORE THAN ONE RACE
16. TOTAL (ADD ITEMS 6 THRU 15)
17. REMARKS:

DATE:

TITLE:

SIGNATURE:

FORM FNS-101 (12-08) Previous Editions Are Obsolete
Electronic Form Version Designed in Adobe 8.1 Version

SBU

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

PARTICIPATION IN FOOD PROGRAMS - BY RACE
This report will be prepared annually covering the month of July.
REPORTING UNITS - Must submit the data to the State agency by the due date established by the State.
STATE AGENCIES AND INDIAN TRIBAL ORGANIZATIONS (ITOs) - Must determine that the data has been
received from all reporting units. The data must be submitted to the appropriate FNS Regional Office by the 19th
of September.
FNS REGIONAL OFFICES - Must determine that the data has been received from all State agencies, ITO's, and
reporting units. The FNS Regional Office must ensure that all data is posted into the Food Programs Reporting
System database by the 20th of November.
Items 1-5 and 17. Self-explanatory.
Items 6-16. Report for each racial group the number of households contacts that participated (received program
benefits or commodities) during July. A household contact is the person who completes the application or is
interviewed. Report only one household contact per participating household. For purposes of this form, "Hispanic
or Latino" is an ethnic group, not a race. In Column A, report the total number of household contacts by race,
including individuals of Hispanic or Latino origin. In Column B, report only household contacts of Hispanic or
Latino origin by race. The form is requesting separate counts for household contacts who chose only one race
and those who chose more than one race.
For item 15, report the total number of household contacts who chose racial combinations that are not included in
items 11 through 14.

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-101 (12-08) Previous Editions Are Obsolete