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pdfFORM APPROVED OMB NO. 0584-0293
Expiration Date: XX/XX/XXXX
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reducing this burden, to: U.S. Department of Agriculture, Food and Nutrition Services, Office of Research and Analysis (0584-0293), Alexandria, VA 22302. Do not return the completed form to this
address.
U.S. DEPARTMENT OF AGRICULTURE
MULTI-FOOD REQUISITION
QUARTER
STATE OR ITD
DISTRIBUTING AGENCY
AVERAGE PARTICIPATION
DELETE
ADD
(SEE INSTRUCTIONS ON REVERSE)
1 D/A CODE
2 DELIVERY
YEAR
9 COMMODITY
CODE
10 COMMODITY
DESCRIPTION
(USE SHORT TITLE)
A060
CHANGE
3 F/R 4 OUTLET 5 ENTITY CODE
D/O NO.
11 EST.
COST
PER LB.
6 CITY
PACK
TYPE
12 NET WT.
PER UNIT
(CASE)
BEANS GREEN 303
24/303
23.40
A090
BEANS VEG 300
24/300
24.00
A095
CARROTS
24/303
24.00
A120
CORN CREAM
24/303
24.00
A121
CORN KERNEL
24/303
24.00
A135
LENTILS
12/2
24.00
A145
PEAS 303
24/303
24.00
A163
PUMPKIN
24/303
24.00
A166
SPINACH
24/303
22.50
A169
POTATOES 303
24/303
24.00
A196
POTATOES DEHY 12
12/1
12.00
A221
SWEET POTATOES 303
24/303
24.00
A244
TOMATO SAUCE 300
24/300
22.50
A248
TOMATOES 303
24/303
24.00
A251
SYRUP P
12/24
25.85
A280
GRAPEFRUIT J
12/46
37.00
A282
APPLE J
12/46
37.50
A285
GRAPE J
12/46
38.00
7 DELIVERY PERIOD
13 QTY.
REQ.
CASES
DISTRIBUTING AGENCY CERTIFICATION
DATE
SIGNATURE
FNS-53 (07/08) Previous editions obsolete
14 TOT. NET
WEIGHT
(LBS.)
15 TOTAL
VALUE
($)
16 ADJ
CODE
17 SECT LAW
18 REDI
FOOD AND NUTRITION SERVICE APPROVAL
REGIONAL OFFICE
SBU
8 REMARKS
Electronic Form Version Designed in Adobe 8.1 Version
DATE
SIGNATURE
Page 1
D/A/CODE
DELIVERY YEAR
9 COMMODITY
CODE
10 COMMODITY
DESCRIPTION
(USE SHORT TITLE)
A286
11 EST.
COST
PER LB.
F/R - D/O NUMBER
PACK
TYPE
12 NET WT.
PER UNIT
(CASE)
PINEAPPLE
12/46
37.70
A290
TOMATO J
12/46
36.50
A300
ORANGE J
12/46
37.50
A355
APPLESAUCE 303
24/303
24.00
A401
F COCKTAIL 303
24/303
24.00
A412
PEACHES CLING 303
24/303
24.00
A439
PEARS 303
24/303
24.00
A446
PINEAPPLE 2
24/2
30.00
A461
PLUMS 303
24/303
24.00
A480
PRUNES 1
24/1
24.00
A502
RAISINS 48
48/1
48.00
A560
POULTRY CND
24/29
43.50
A562
CHICKEN CND
24/29
43.50
A570
EGG MIX 6
48/6
18.00
A587
STEW CND
24/24
36.00
A589
STEW 24/15
24/15
22.50
A610
BEEF NJ
24/29
43.50
A617
LUNCHMEAT P 24
24/30
45.00
A619
LUNCHMEAT 24
24/30
45.00
A630
PORK NJ
24/29
43.50
A740
TUNA 12.5
24/12.50
18.75
A741
TUNA 12.25
24/12.25
18.37
A800
SALMON PINK
48/14.75
44.25
FNS-53 (07/08) Previous editions obsolete
13 QTY.
REQ.
CASES
DELIVERY PERIOD
14 TOT. NET
WEIGHT
(LBS.)
15 TOTAL
VALUE
($)
16 ADJ
CODE
17 SECT LAW
18 REDI
Page 2
D/A/CODE
DELIVERY YEAR
9 COMMODITY
CODE
10 COMMODITY
DESCRIPTION
(USE SHORT TITLE)
A910
11 EST.
COST
PER LB.
F/R - D/O NUMBER
PACK
TYPE
12 NET WT.
PER UNIT
(CASE)
BEANS BLKEYE 2
12/2
24.00
A912
BEANS B LIMA 2
12/2
24.00
A914
BEANS PINTO 2
12/2
24.00
A917
BEANS GRT NORTH 2
12/2
24.00
A918
BEANS NAVY PEA 2
12/2
24.00
A920
BEANS LT KIDNEY 2
12/2
24.00
A922
PEAS SPLIT 2
12/2
24.00
B050
BUTTER 36
36/1
36.00
B060
CHEESE 30
6/5
30.00
B081
EVAP 12
48/12
40.00
B090
INSTANT 24
6/4
24.00
B137
CORNMEAL 5 DEG
10/5
50.00
B141
CORNMEAL 10 DEG
5/10
50.00
B160
FARINA
24/14
21.00
B161
CEREAL INFANT R8
12/8
6.00
B162
FORMULA SOY DRY
6/14
6.25
B163
FORMULA SOY 12
12/13
10.75
B165
FORMULA
24/13
21.50
B166
FORMULA SOY
24/13
21.50
B167
FORMULA POWDER
12/1
12.00
B168
FOMULA POWDER 6
6/1
6.00
B179
FLOUR AP 5
10/5
50.00
B180
FLOUR AP 10
5/10
50.00
B229
FLOUR B 5
10/5
50.00
FNS-53 (07/08) Previous editions obsolete
13 QTY.
REQ.
CASES
DELIVERY PERIOD
14 TOT. NET
WEIGHT
(LBS.)
15 TOTAL
VALUE
($)
16 ADJ
CODE
17 SECT LAW
18 REDI
Page 3
D/A/CODE
DELIVERY YEAR
9 COMMODITY
CODE
10 COMMODITY
DESCRIPTION
(USE SHORT TITLE)
B230
11 EST.
COST
PER LB.
F/R - D/O NUMBER
PACK
TYPE
12 NET WT.
PER UNIT
(CASE)
FLOUR B 10
5/10
50.00
B349
FLOUR WW 5
10/5
50.00
B350
FLOUR WW 10
5/10
50.00
B367
FLOUR MIX
6/5
30.00
B403
HONEY 24
24/24
36.00
B425
MACARONI 1
24/1
24.00
B445
OATS 3
12/3
36.00
B470
PB 2
24/2
48.00
B501
ROASTED 12
24/12
18.00
B510
RICE 2
24/2
48.00
B570
WHEAT 3
12/3
36.00
B666
VEG OIL 48
10/5
23.10
B720
SHORT S 3
12/3
36.00
B835
SPAGHETTI 2
12/2
24.00
B850
CEREAL CORN
24/18
27.00
B851
CEREAL CORN 16
14/16
14.00
B852
CEREAL CORN 17.5
12/17.5
13.13
B860
CEREAL OATS
24/15
22.50
B861
CEREAL OATS 16
12/16
12.00
B864
CEREAL RICE
24/13
19.50
B866
CEREAL RICE 12
12/13
9.75
B867
CEREAL RICE 17.5
12/17.5
13.13
B870
CEREAL WHEAT
24/18
27.00
B871
CEREAL WHEAT 16
12/16
12.00
FNS-53 (07/08) Previous editions obsolete
13 QTY.
REQ.
CASES
DELIVERY PERIOD
14 TOT. NET
WEIGHT
(LBS.)
15 TOTAL
VALUE
($)
16 ADJ
CODE
17 SECT LAW
18 REDI
Page 4
INSTRUCTIONS
(For State Distributing Agency or Indian Tribal Organization)
ITEM:
QUARTER - Enter the quarter provided by the FNS Regional Office for School Year in
which shipment is to be made. Example: Q1 (for January, February, or March); Q2, Q3,
or Q4.
STAFF - Enter the two-letter State Code in which the Distributing Agency is located.
Example: For UTE Mountain Tribe in Colorado you would enter CO.
NAME OF DISTRIBUTING AGENCY - Enter the name of the Distributing Agency.
AVERAGE PARTICIPATION - Enter the average number of participants served by the
program.
TYPE OF ACTION - Place an "X" in the applicable category. (Delete, Add, or Change).
BLOCK:
1. DA CODE - Enter the three-digit code number of the Distributing Agency.
2. DELIVERY YEAR (ALPHA) - Enter the alphabetical designation provided by the FNS
Regional Office for the School Year in which shipment is made.
3. FOOD REQUISITION/DELIVERY ORDER NUMBER - Use the same number for both
categories. Assign numbers unless advised by the FNS Regional Offices. The numbers
should begin with 501 each school year, continuing numerically through 899.
4. OUTLET - Enter the appropriate outlet as follows: CSFP for Commodity Supplemental
Food Program; FDIR for Food Distribution Program on Indian Reservations.
5. ENTITY CODE - The entity code is provided by the Kansas City Commodity office
(KCCO) for each given destination.
6. CITY - The City should be spelled out in its entirety.
7. DELIVERY PERIOD (NUMERICAL) - Enter the beginning and ending delivery period
desired. First half: 01/15/98 Second half: 01/31/98.
8. REMARKS - For use by the Distribution Agency or the Regional Office. Indicate (by
city) if shipment should be combined. Example: "Combine w/Rochester." Also list
information important for KCCO to receive such as "No deliveries on Friday."
9. COMMODITY CODE - Items are preprinted. If new item, check with FNS Regional
Office for correct code.
10. COMMODITY DESCRIPTION "SHORT TITLE" - Items are preprinted. If new item,
check with FNS Regional Office for correct short title.
11. ESTIMATED COST PER POUND - Optional entry, cost per pound of a commodity.
12. NET WEIGHT PER UNIT (CASE)/Baler - Items are pre-printed.
13. QUANTITY REQUESTED - (CASES)/Balers: Enter the number of full cases/balers
requested.
14. TOTAL NET WEIGHT PER ORDER (POUNDS) - Enter net pack weight per order
(pounds). Net pack weight x units requested = Net weight per order. Total weight per
truckload should not exceed 36,000 pounds net weight. Weight must be adjusted
downward when ordering bulky light weights items such as adult cereal.
15. TOTAL VALUE - Optional entry, total net weight x estimated cost equals total value.
The following categories should be left blank, for FNS Regional Office or FNS
Headquarters to complete:
16. ADJUSTMENT CODE - (Leave Blank)
17. SECTION LAW - (Leave Blank)
18. REDONATION CODE - (Leave Blank)
DISTRIBUTING AGENCY CERTIFICATION - The person who executed the
"Agreement for Distribution" and use of Donated Commodities (Form
FNS-51) on behalf of the Distributing Agency, or his/her designee, shall sign
and date in ink or indelible pencil.
(For FNS Regional Office)
BLOCK:
3. DELIVERY ORDER/FOOD REQUISITION NUMBER - Begin with 501,
continuing numerically through 899.
8. REMARKS Optional.
16. ADJUSTMENT CODE - Refer to IT instructions for appropriate
adjustment codes and their use.
17. SECTION LAW - Commodity Supplemental Food Program (CSFP) - 17
Food Distrubtion Program on Indian Reservations (FDIR) - 4a.
Bonus Commodities - 416 (Verify with FNS Headquarters for an updated list
of bonus commodities and eligible outlets).
18. REDONATION CODE - Refer to IT instructions for appropriate
redonation codes and their use.
FOOD AND NUTRITION SERVICE APPROVAL - The FNS Regional Office
employee who is authorized to approve Food Requistions will show the
appropriate Regional Office (SERO, MPRO, etc.), and sign and date. This
approval by Regional Office indicates that States or Tribal Inventory levels
have been checked out and the orders have been prepared in accordance
with these instructions.
DISTRIBUTION:
1. The Distribution Agency shall retain one copy and forward the original and
other copies with carbon inserts to the FNs Reigonal Office.
2. After approval for multi-food shipments, the FNS Regional Office will send
one copy with any changes to the Distribution Agency. The Regional Office
will retain the original.
File Type | application/pdf |
File Modified | 2009-10-29 |
File Created | 2007-06-21 |